Virginia Group Applications and Forms

You’ll find a variety of applications and other forms available. Contact your Account Manager or Broker Representative to ensure you’re using the correct forms. Please choose from the list below:

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BluePreferred

Group & Member Applications - BluePreferred
Average Age/Factor Adjustment Form
Miscellaneous Forms - BluePreferred

BlueChoice Advantage and BlueChoice Advantage 2.0

Group & Member Applications - BlueChoice Advantage
Miscellaneous Forms - BlueChoice Advantage

BlueChoice HMO and BlueChoice HMO Open Access

Group & Member Applications - BlueChoice HMO and BlueChoice HMO Open Access
Average Age/Factor Adjustment Form
Miscellaneous Forms - BlueChoice HMO and BlueChoice HMO Open Access

BlueChoice Opt-Out Open Access

Group & Member Applications - BlueChoice Opt-Out Open Access
Average Age/Factor Adjustment Form
Miscellaneous Forms - BlueChoice Opt-Out Open Access

BlueChoice Opt-Out Plus Open Access

Group & Member Applications - BlueChoice Opt-Out Plus Open Access
Average Age/Factor Adjustment Form
Miscellaneous Forms - BlueChoice Opt-Out Plus Open Access

Consumer Directed Health Plans (CDH)

BluePreferred Group & Member Applications and Enrollment Forms
BlueChoice HMO Open Access Group & Member Applications and Forms
BlueChoice Opt-Out Plus Open Access Group & Member Applications and Forms
BlueChoice Advantage Group and Member Applications and Enrollment Forms

Grandfathering Notice of Intent Forms

Group Grandfathering Notice of Intent Forms

Dental

Group & Member Applications - Preferred (PPO), Traditional, BlueDental Plus, BlueDental EPO & BlueDental Basic
Group & Member Applications - BlueDHMO

Vision

Group & Member Applications - Vision

Flexible Spending Account

Flexible Spending Account (FSA) Proposal Request Form
FSA Plan Design Guide

Disclosure Statements

BlueChoice Renewal Statement
BlueChoice New Sales Statement
CareFirst (PPN, MPOS, BluePreferred) Renewal Statement
CareFirst (PPN, MPOS, BluePreferred) New Sales Statement

Traditional - NCA Products Only

Group & Member Applications - Traditional NCA Products Only
Miscellaneous Forms - Traditional NCA Products Only

Protected Health Information (PHI) Forms

Authorization Form for Information Release
Personal Representative Form
Revocation Authorization Personal Representative Designation
Access to PHI Form
Accounting of Disclosures
Amendment to PHI Form
Restrict PHI Form
Terminate Restriction to PHI Form
Request for Confidential Communications Form

This form should be returned to:

CareFirst BlueCross BlueShield
Privacy Office
PO Box 14858
Lexington, KY 40512
Fax: 1-410-505-6692

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