Helpful forms for your business

• Electronic Enrollment Authorization Form
  To authorize the administrator to conduct enrollment for your account
• Electronic Payment Option Form
  To have your group's monthly premium payment electronically deducted from your group's checking account. Please note: The electronic payment option is only available to groups purchasing health and/or dental coverage directly with BCBSRI. If you purchased coverage through HealthSource RI, please call 1-855-651-7873 for information about payment options.
• Group Activity Report (GAR) and Instructions (PDF Version)
  To enroll new subscribers, cancel coverage for subscribers, process changes in family status (such as the birth of a child or marriage), or to change plan coverage
• Group Dependent Addendum
  To add more dependents with a Group Member Application
• Small Group New Business Checklist
  Keep track of each part of the process
• Group Plan 65 Member Application
• Group Plan 65 Plan Options
• Small Group Enrollment Guidelines
  For adding and terminating coverage for employees
• Small Group Member Application
  For medical, dental, and vision insurance
• Small Employer Waiver Form/Certification
  For employees who do not want coverage through their employer
• Small Group Domestic Partner Coverage Offering Election Form

• Electronic Enrollment Authorization Form
• Electronic Payment Option Form
  To have your group's monthly premium payment electronically deducted from your group's checking account. Please note: The Electronic Payment Option is only available to groups purchasing health and/or dental coverage directly with BCBSRI. If you purchased coverage through HealthSource RI, please call 1-855-651-7873 for information about payment options.
• Group Activity Report (GAR) and Instructions (PDF Version)
• Group Dependent Addendum
• Group Plan 65 Member Application
• Group Plan 65 Plan Options
• Large Group Enrollment Guidelines
• Large Group Member Application
• BCBSRI Insured Large Group Domestic Partner Coverage Offering Election Form

Self-Funded Employers

• Plan Sponsor Manual for Self-Funded Clients
• BCBSRI Self Funded Group Domestic Partner Coverage Offering Election Form
• Finance Intake Form
• Retroactive Enrollment Exception Form

To start the recertification process, you must complete the Renewal Certification form and return it to Blue Cross with your supporting payroll tax documentation and waivers.

• Recertification Checklist
  A handy list to help you make sure you’ve got everything you need
• Initial Letter Attestation
  This explains the importance of returning the attestation form (below)
• Small Employer Attestation Form
• Letter Regarding Certification
  This explains the importance of recertification
• Renewal Certification Form

The documents below are examples of commonly used proof of ownership and payroll documents.

• Quarterly Tax and Wage Report
• Schedule C (Form 1040)
• Schedule K-1 (Form 1120s)
• Schedule K-1 (Form 1065)
• W-4 Form

Email to:
recertification@bcbsri.org

Fax to:
Small Group Underwriting - Recertification Unit at (401) 459-5445

Envie por correio para:
Blue Cross & Blue Shield of Rhode Island
Small Group Underwriting Recertification Unit
500 Exchange Street, Providence, RI 02903

• PCP Selection Form
  Each member should choose a primary care provider (PCP)
• Affidavit of Common Law Marriage
• Declaration of Domestic Partnership

• International Claim Form
  This claim form is used when services are rendered outside of United States.
• Member Reimbursement Donor Egg and Sperm
  Complete and submit this form to request reimbursement for this service.
• Member Reimbursement Oral Enteral Food Products Form
  Complete and submit this form to request reimbursement for these products.
• Travel Benefit Reimbursement Form
  Complete and submit this form to request reimbursement for this service.
• Cell Storage Reimbursement Form
  Complete and submit this form to request reimbursement for this service. This applies to members covered by the expanded fertility policy.
• Cell Shipping Reimbursement Form
  Complete and submit this form to request reimbursement for this service. This applies to members covered by the expanded fertility policy.
• Member Reimbursement Donor Egg and Sperm - Expanded Fertility Policy
  Complete and submit this form to request reimbursement for this service. This applies to members covered by the expanded fertility policy.