Virginia Group Applications and Forms

A variety of applications and other forms are available.

Please contact your Account Manager or Broker Representative to ensure that you have 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

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

HealthyBlue

HealthyBlue HMO, 2.0 and Triple Option - Group & Member Applications

HealthyBlue Advantage - Group & Member Applications

HealthyBlue PPO - Group Applications & Forms

Average Age/Factor Adjustment Form

HealthyBlue Miscellaneous 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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