Applications and Forms - Broker and Agent Services

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Applications & Forms

A variety of applications and other forms are available for Brokers. Please choose from the list below:

Note: The following BlueFund Consumer Driven Health (CDH) applications & forms are now available:

BluePreferred

Group & Member Applications
Protected Health Information (PHI) Forms
Average Age Adjustment Form word icon

Miscellaneous Forms

BlueChoice Advantage

Group & Member Applications

BlueFund CDH - BluePreferred

Group & Member Applications and Enrollment Forms
Deductible Credit Claim Form PDF icon

FlexAmerica HSA Application PDF icon

Accelerated HSA Application PDF icon

HSA Late Submission Form PDF icon

FlexAmerica HRA Application

HRA Debit Card - Existing Accounts

ACS/Mellon Trustee to Trustee Transfer Form

BlueChoice HMO and
BlueChoice HMO Open Access

Group & Member Applications
Protected Health Information (PHI) Forms
Average Age Adjustment Form word icon

Miscellaneous Forms

BlueFund CDH - BlueChoice HMO Open Access

Group & Member Applications and Enrollment Forms
Deductible Credit Claim Form

FlexAmerica HSA Application

Accelerated HSA Application PDF icon

HSA Late Submission Form

FlexAmerica HRA Application

HRA Debit Card - Existing Accounts

ACS/Mellon Trustee to Trustee Transfer Form

BlueChoice Opt-Out Open Access

Group & Member Applications
Protected Health Information (PHI) Forms
Average Age Adjustment Form word icon

Miscellaneous Forms

BlueChoice Opt-Out Plus and
BlueChoice Opt-Out Plus Open Access

Group & Member Applications
Protected Health Information (PHI) Forms
Average Age Adjustment Form word icon

Miscellaneous Forms

BlueFund CDH - BlueChoice Opt-Out Plus Open Access

Group & Member Applications and Enrollment Forms
Deductible Credit Claim Form

FlexAmerica HSA Application

Accelerated HSA Application PDF icon

HSA Late Submission Form

FlexAmerica HRA Application

HRA Debit Card - Existing Accounts

ACS/Mellon Trustee to Trustee Transfer Form

CareFirst Regional Dental Freestanding

Group & Member Applications
Authorization Agreement for ACH Debit

DHMO Dental Freestanding

Forms and Applications

CFMI Small Group Regional Dental

Information Form

CareFirst Regional Vision Freestanding

Group & Member Applications
Authorization Agreement for ACH Debit

Flexible Spending Account

FSA Application

FSA Brochure & Fee Schedule

Disclosure Statements

BlueChoice Renewal Statement

BlueChoice New Sales Statement

CareFirst (PPN, MPOS, BluePreferred) Renewal Statement

CareFirst (PPN, MPOS, BluePreferred) New Sales Statement

Maryland Point of Service (MPOS)

Member Applications
Protected Health Information (PHI) Forms

Preferred Provider Network (PPN)

Member Applications
Protected Health Information (PHI) Forms

Premium Only Plan

Brochures & Forms

Traditional - NCA Products Only

Group & Member Applications
Protected Health Information (PHI) Forms
Miscellaneous Forms

This information was last updated in January 2007. Please contact your Account Manager or Broker Representative to ensure that you have the correct forms.

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