Excellus Bluecross BlueShield logo
Login | Register | Forgot Username | Forgot Password
Quick Links
Program Offerings
By Phone
By Email
By Mail
Visit Us In-Person
News & Updates
Print Forms
About Us
Compliance Notices
Forms for Brokers
Forms for Brokers
Enrollment forms listed below are for groups with 51 plus employees. Please obtain form from Blue on Demand if the employer group is under 51 employees.

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

Broker Authorization Forms
  • Medical & Dental Enrollment Forms
  • Blue PPO, Blue EPO, Classic Blue, Blue Preferred PPO, Dental
  • Blue Choice, BluePoint2, BluePoint3, Dental
  • Member Enrollment Form - All Other Group Plans
  • Healthy New York Group Enrollment Form
  • HealthyBlue
  • HealthyBlue HDHP
  • SimplyBlue
  • SimplyBlue HDHP
  • Medicare Enrollment Forms
  • Medicare HMO or PPO - Rochester Region
  • Medicare PPO - All Other Regions
  • Medicare Traditional
  • Medicare Eligibility Form
  • 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
  • Eligibility Certification Forms
  • Adoption or Foster Dependent Form
  • Employer Setup Form for Integrated HSA
  • 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
  • Young Adult Option Certification Form
  • Direct Purchase Enrollment Forms
  • Non-Group Conversion Application
  • Non-Group (Direct Purchase) Membership Application
Home     News & Updates    Print Forms    About Us    Fraud & Abuse    Glossary    Accreditations   
Copyright © 2014, Excellus BlueCross BlueShield, a nonprofit independent licensee of the Blue Cross Blue Shield Association. All rights reserved. View our Privacy Policy for information on how we protect your privacy. Use of this site indicates your acceptance of our Terms of Use. Follow this link to view our 31 county New York State service area. You will need Internet Explorer or Firefox to use the secure features of this site.