| Dental Plans Applications |
| Anthem Blue Cross of California |
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| Blue Shield |
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| Delta Dental MorganWhite |
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| Golden West |
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| Kaiser Permanente |
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| Standard Life MorganWhite |
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Forms
Download Instructions:
Adobe Acrobat Reader software is required to view, print
and search these PDF documents. Please download this free software on
the Adobe Acrobat Web site. Please note that Blue Cross of California
does not provide Technical Support for Acrobat Reader Software. For
technical support, please contact Adobe.
To use these forms:
1. Download and install Acrobat Reader.
2. Select the form you would like to complete.
3. Use Acrobat Reader and your printer to print the form.
4. Fill out the printed form.
5. See the form for specific mailing information.
Download
Member Claim Form
Usually providers of health care bill Blue Cross directly
for services to you and your enrolled dependents. However, if you have
to submit a claim for medical services you must complete this form.
Please see page 2 of this form for instructions on how to complete this
form and submit it to Blue Cross.
Individual Enrollment Application
Complete this form for any of the following reasons.
If the dependent you want to add to your contract is
a newborn (i.e. under 60 days old), you can add him/her to your contract
by contacting us at the customer service number listed on your ID card,
or by sending us a written request. Please include the policies primary
member ID number, full name of newborn, date of birth and gender. You
may fax this request to Membership Services at (805) 480-8813.
Exceptions to Standard Enrollment
The signature dates on the Individual Enrollment Application or
Change of Coverage Application are valid for 30 days. If,
when your application is being processed, the signature date(s)
exceeds 30 days, you will be required to complete and submit this
form. This usually happens when you sign the application long before
you mail it to Blue Cross.
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Life & Disability Forms
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| Standard Health Plans Applications |
| Aetna |
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| Anthem BC Life and Health Insurance Company Tonik |
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| Anthem Blue Cross of California |
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| Blue Shield of California |
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| Health Net of California |
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| Health Net of California Farm Bureau |
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| Kaiser Permanente |
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| Temporary Health Plans Applications |
| Anthem BC Life and Health Insurance Company |
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| Assurant |
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| Health Net of California |
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| Health Plans |
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