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Forms for Employers
Enrollment forms listed below are for groups with 51 plus employees. Please see your account manager or broker if the form you need is not listed.

Image Link: Get Adobe ReaderUse the links below to print/view copies of our most frequently used forms. All forms are in a PDF format. If you don't already have Acrobat® Reader, you can download it free at Adobe.com

Employer Access for Web Enrollment & Updates
  • Medical & Dental Enrollment Forms
  • Blue Choice, BluePoint2, BluePoint3, Dental
  • Blue PPO, Blue EPO, Classic Blue, Blue Preferred PPO, Dental
  • HealthyBlue
  • HealthyBlue HDHP
  • SimplyBlue
  • SimplyBlue HDHP
  • Member Enrollment Form - All Other Group Plans
  • Healthy New York Group Enrollment Form
  • Medicare Enrollment Forms
  • Medicare HMO or PPO - Rochester Region
  • Medicare PPO - All Other Regions
  • Medicare Traditional
  • Medicare Eligibility Form
  • Eligibility Certification Forms
  • Adoption or Foster Dependent Form
  • Away From Home Care Guest Membership Application
  • Continuing Coverage for Students on Medical Leave Form
  • Dependent Certification Form
  • Domestic Partner Affidavit Form
  • Handicapped Dependent Application
  • Qualified Medical Child Support Order Certification Form
  • Qualified Medical Child Support Order Disenrollment Form
  • Young Adult Option Certification Form
  • Direct Purchase Enrollment Forms
  • Non-Group Conversion Application
  • Non-Group (Direct Purchase) Membership Application
  • Claim Forms
  • $300 BlueHealthy Dollars Reimbursement Form
  • Claim Form
  • Dental Claim Form
  • Prescription Drug Claim Form
  • Prescription Drug Claim Form (for services in 2011)
  • Go Getters Claim Form
  • Blue Healthy Choices Lifestyle Benefits Reimbursement Form
  • SimplyBlue Gym Membership Incentive Reimbursement Form
  • For Flexible Spending Account (FSA) or Medical Reimbursement Account forms, please visit the EBS-RMSCO website
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