Forms

Affidavit of Domestic Partnership - Group Legally establish a domestic partnership for the purposes of enrolling your partner on your health insurance plan.
Affidavit of Domestic Partnership - Individual Legally establish a domestic partnership for the purposes of enrolling your partner on your health insurance plan.
Direct Bill COBRA Paperwork COBRA and New York Continuation of Benefits billing.
Disability Certification Form Certification of an unmarried child's disability and eligibility for continued coverage.
Master Group Contract A blank copy of the Group Health Care Contract between a group and BlueCross BlueShield of Western New York
Format for Adhoc letters
Student Dependent Verification Form This form must be completed to verify that your dependent age 19 or over is a full-time student at an accredited college or university.
Subscriber Claim Form Medical benefits subscriber claim form.
Termination Request Form All subscriber terminations must be written on this form to be processed properly.

HIPAA Privacy Authorization (Form 2A) Completing this form permits release, in most instances, of general health information to the person(s) named in the form(s). This version does NOT allow for the release of HIV/AIDS, Mental Health, Alcohol or Substance Abuse information.
HIPAA Form 2(D) Authorization for Release of HIV Information Completion of this form will ONLY allow the release of HIV/AIDS information.
HIPAA Form 2(E) Authorization for Release of Confidential Medical Records Related to Alcohol and Substance Abuse and Mental Health Completion of this form will ONLY allow the release of Mental Health, Alcohol or Substance Abuse information.
HIPAA Form 2I - Plan Sponsor Certification of Group Health Plan Plan sponsor certification of group health plan HIPAA compliance
How to Complete Plan Sponsor Certification of Group Health Plan HIPAA