Arkansas Blue Cross and Blue Shield

Forms for Employers

These forms are in portable document format (PDF). You may print and copy as needed.

• Application for Conversion Policy (PDF)
  
  
• Blueprint for Employers Registration Form (PDF)
  
  
• Blueprint for Employers Web Administrator Change Form (PDF)
  
  
• Change Request Form (PDF) (Not for use by BluesEnroll Groups)
  
  
• Dental Application and Change Form (PDF) To make a change, please complete this form and return it to your group administrator.
  
  
• Dental Claim Form (PDF)
  
  
• Group Administrator's Manual (PDF)
  
  
• Health Claim Form (PDF)
  
  
• Large Group Employee Application (PDF)
  
  
• Medical Questionnaire for Late Enrollees (PDF)
  
  
• Newborn Enrollment Request (PDF)
  
  
• Physician Incapacity Letter (PDF)
  
  
• Prescription Claim Form (PDF) This claim form should not be used by CHIP policyholders. Prescription drug claims for CHIP policyholders should be filed using the Medical Claim Form linked above.
  
  
• Small Group Employee Application (PDF)
  
  
• Student Verification Form (PDF)
  
  
• State of Arkansas Continuation of Coverage Election Form (PDF)
  
  
• Subscriber's Incapacity Form (PDF)