Don't find
the form you need? Order it from
our Supply Specialist at (503) 225-4961.
| Forms |
Descriptions |
| ENROLLMENT FORMS |
| New
Enrollment and Change Form (PDF) |
Use this form to add a new employee
to your group plan or make changes such as
adding/deleting dependents, name change or changes
at open enrollment. |
| Regence
Life & Health Enrollment Application (PDF) |
Use this
from to collect beneficiary information from your
employees if you have Regence Life & Health
Benefits. (This form is kept by the employer, not
by Regence BlueCross BlueShield of Oregon.) |
| Waiver
of Coverage
(PDF) |
Use this form for employees who decline
health-care coverage through Regence BlueCross BlueShield
of Oregon. |
| Employee
Enrollment Form (PDF) |
Insurance Pool Governing Board (IPGB)
form for Blue Solution only |
| Employer
Enrollment Data (PDF) |
Insurance Pool Governing
Board (IPGB) form for Blue Solution only |
| COBRA/CONTINUATION
FORMS |
| COBRA
Application and Notice (PDF) |
Use this form when an employee or
dependent chooses to continue group coverage after
a qualifying event. This form is for Oregon- and
Washington-based groups of 20 or more employees. |
| COBRA
Qualification Worksheet (PDF) |
Use this worksheet to
see if your group qualifies for COBRA. |
| Oregon
Continuation Application and Notice (PDF) |
Use this form when an
employee or dependent chooses to continue group
coverage after a qualifying event. This form is
for Oregon-based groups with fewer than 20 employees. |
| Washington
Continuation Application and Notice (PDF) |
Use this form when an
employee or dependent chooses to continue group
coverage after a qualifying event. This form is
for Washington-based groups with fewer than 20 employees. |
| AUTHORIZATION FOR
USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION |
| Authorization
for Use and Disclosure of Protected Health Information (PDF) |
Authorization for Regence BlueCross
BlueShield of Oregon and/or a member's health-care
providers to disclose health information to a
designated party for a specific purpose. |
VERIFICATION FORMS |
| BlueChoicesSM
Accidental Death Claim Form (PDF) |
Applicable to Oregon
based groups, sizes 2-199, with BlueChoices products
only. Use this form when an enrolled employee, spouse
or dependent passes away due to an accidental death. |
| Affidavit of Qualifying Incapacitated Dependent Eligibility (PDF) |
Use this form to certify that your eligible dependent child is incapacitated due to medical disability, developmental disability or mental disorder. |
| Certificate
of Paternity (PDF) |
Use this form to prove that a individual
is the natural father of a dependent. |
| Certification
of Dependency (PDF) |
Use this form to prove that an individual
is a legal dependent of the member (usually required
for dependents other than natural children). |
| Affidavit
of Domestic Partner (PDF) |
Employees and their domestic
partners applying for coverage should complete this
form. Domestic partner coverage is available to
select groups with more than 50 subscribers. |
| Certification
of Marriage (PDF) |
Use this form to provide
information regarding an employee's marriage status
in cases where the eligibility of the spouse is
in question (e.g., different last names). |
| Certification
of Placement - Oregon (PDF) |
Use this
form when a child has been adopted or physically
placed with an employee for the purposes of adoption.
The employee must assume financial responsibility
for the dependent's medical expenses. |
| Certification
of Placement - Washington (PDF) |
Use this form when a child has been
adopted or physically placed with an employee for
the purposes of adoption. The employee must assume
financial responsibility for the child's medical
expenses. |
| Statement
of Termination of Domestic Partnership (PDF) |
Use this form to indicate the termination
of a domestic partnership due to change in circumstance
or death. |
| Employer
Affidavit (PDF) |
Insurance Pool Governing Board (IPGB)
form for Blue Solution only |
PRESCRIPTION MEDICATION
MAIL-ORDER FORMS
Now located on the RegenceRx
Web site. |
PRESCRIPTION AND
DURABLE MEDICAL EQUIPMENT REIMBURSEMENT FORM |
| Direct Member Reimbursement Form (PDF) |
Use this form to submit claims for for reimbursement on covered services that require payment out of pocket . |
| Rx
Reimbursement Form (PDF) |
Use this form to submit
paper claims on Argus prescription medication card
plans. |
| Traditional
DME Claim Form (PDF) |
Use this form to submit
a durable medical equipment claim for reimbursement on PPO and Traditional
plans. |
| Durable Medical Equipment & Medical Supply Claim Form (PDF) |
Use this form to submit claims
for durable medical equipment or prescription plans that
require members to pay out of pocket and submit for
reimbursement. |
| REGENCE PERSONAL CHOICE
ACCOUNT FORMS |
| Plan
Application (PDF) |
Use this form to apply for a Regence
Personal Choice Account. |
| Enrollment
Authorization and Agreement (PDF) |
Use this form to enroll an employee
in a Regence Personal Choice Account. |
| FORMS REQUESTING ADDITIONAL
INFORMATION |
| Coordination
of Benefits Report (PDF) |
Use this form when Regence
needs to verify a member's other insurance coverage. |
| Incident
Report (PDF) |
Use this form to verify
accident information and third-party liability. |
| FORMS FOR GROUP ADMINISTRATOR
USE ONLY |
| Application
for Group Coverage (PDF) |
Use this form to provide initial
group setup information. If your group size is
2-50 in Oregon, or 1-50 in Washington, please
use our Online
Enrollment System. |
| Annual
Census Form - Oregon (PDF) |
Use this form annually
to verify group information. Use this form for Oregon-based
groups with 50 or fewer employees only. |
| Annual
Census Form - Washington (PDF) |
Use this form annually
to verify group information. Use this form for Washington-based
groups with 50 or fewer employees only. |
| Application
for Group Coverage - AFC (PDF) |
Use this form to provide
initial group setup information. For groups of 51
or more eligible employees only. |
| Eligibility
Adjustments (PDF) |
Use this form to calculate premium
due when new enrollment, status changes or member
cancellations have been made. |
| TruVision™ (PDF) |
Our new discount vision care program |
| Group
Census (PDF) |
Insurance Pool Governing
Board (IPGB) form for Blue Solution only |
| SPANISH FORMS |
| New
Enrollment and Change Form (PDF) |
Use this form to add
a new employee to your group plan or make changes
such as adding/deleting dependents, name change
or changes at open enrollment. |
| Waiver of Coverage (PDF) |
Use this form for employees who decline health-care coverage through Regence BlueCross BlueShield of Oregon. |
Don't find the form you need? Order it from our Supply Specialist at (503) 225-4961.
