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Forms

As a service, we have provided a current list of our most common forms for your use. All forms are in Adobe Acrobat format.

The latest version of the Adobe Acrobat Reader software is required to view, print and search these PDF documents. Please download this free software from the Adobe Acrobat Web site. Please note that Blue Cross and Blue Shield of Georgia does not provide Technical Support for Acrobat Reader Software. For technical support, please contact Adobe.

Member Applications

Small Group (2-50 employees)

Large Group (51-99 employees)

Large Group (100+ employees)

Member Change Forms

GGL Beneficiary Change Form

Small Group (2-50 employees)

Large Group (51+ employees)

HIPAA Forms

General Member Authorization Form Instructions

General Member Authorization Form

Conditioned Authorization Form - Instructions

Conditioned Authorization Form

Life & Disability Forms

Life & Disability Forms

Miscellaneous Forms

SB476 Aknowledgement Form

Small Group Cancellation Form

Large Group Cancellation Form

FSA Enrollment Form

Small Group Employer Reference Guide Order Form

HDHP/HSA

HSA Group Initiation Form

HSA Application - Group Member

HSA Application Addendum

COBRA Forms

CSWA Access Code Policy and Usage Agreement

CSWA Initial Enrollment Info

CSWA User Manual

COBRA Solutions Notification Form

COBRA Solutions Application

COBRA Solutions Service Agreement

Compliance made easy with COBRA solutions

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Blue Cross and Blue Shield of Georgia and Blue Cross Blue Shield Healthcare Plan of Georgia are independent licensees of the Blue Cross and Blue Shield Association