Downloadable Forms for Individual Products
Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of Oklahoma (BCBSOK). To access more downloadable forms, please log in to Blue Access for Producers.
The forms below are in portable document format (PDF). To view these files, you may need to install a PDF reader program. Most PDF readers are a free download. One option is Adobe® Reader®.
Current Individual Forms |
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| Stock # / Date | Enrollment Forms and Change Forms | Oklahoma Form # |
| 606465.1020 | 2021 Individual Paper Application Checklist  |
N/A |
| 73447.1020 | Health Application/Change in Coverage – Use this health application for 2021 plans, effective January 1, 2021. |
N/A |
| 600001.1020 | Dental Application/Change in Coverage – Use this dental application for 2021 plans, effective January 1, 2021. |
N/A |
| 601673.1020 | 2021 Individual Paper Application Overflow Page |
N/A |
| TBA | 2022 Individual Paper Application Checklist |
N/A |
| TBA | Health Application/Change in Coverage – Use this health application for 2022 plans, effective January 1, 2022. |
N/A |
| TBA | Dental Application/Change in Coverage – Use this dental application for 2022 plans, effective January 1, 2022. |
N/A |
| TBA | 2022 Individual Paper Application Overflow Page |
N/A |
| Stock # / Date | Account Maintenance Forms | Oklahoma Form # |
| 72008.1018 | Auto Bill Pay - Automatic Premium Payment Authorization Agreement |
N/A |
| 600901.1018 | Auto Bill Pay - Automatic Premium Payment Authorization Agreement - Spanish |
N/A |
| 608020.0719 | Disabled Dependent Authorization Form (for Individual Plans) – Members with an Individual health plan should use this form to request continuation of coverage on their existing policy for a dependent who is incapable of self-support because of mental or physical impairment. Mail or fax the completed form to BCBSOK (see address and fax number at the top of the form). |
N/A |
| Stock # / Date | Legal / HIPAA Forms | Oklahoma Form # |
| 04.01.18 | Standard Authorization Form and other HIPAA Privacy Forms | N/A |
Pre-ACA Individual Forms |
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| Stock # / Date | Enrollment Forms and Change Forms | Oklahoma Form # |
| 72120.1113 | Health Check and Simply Blue Individual Application and Change in Membership |
N/A |
| Stock # / Date | Legal / HIPAA Forms | Oklahoma Form # |
| 04.01.18 | Standard Authorization Form and other HIPAA Privacy Forms | N/A |
