Member forms- Employer coverage

Note: Some employers use customized forms or electronic systems. Please check with your Human Resources office before using one of these forms.

Group Administrator's Signature Required

• Active employee application for out-of-area classification [pdf]
  Active Employees of Arkansas-based employer groups that live outside of Arkansas for more than 90 days may have access services covered by Health Advantage on the employee’s group health plan, if approved.
• Address change form [pdf]
• Change request form [pdf]
  Use this form to request a change to your current policy, such as name changes, beneficiary change, member termination and more. (Note that this form is used only for groups that submit paper application forms.)
• Newborn enrollment request [pdf]
  A newborn child may be covered from the date of birth if the newborn is enrolled within 90 days of the date of birth.
• State of AR continuation of coverage election [pdf]

Group Administrator's Signature Not Required

• Arkansas Blue Cross employees/dependents/retirees: Designation for authorized appeal representative form [pdf]
• Authorization for release of information and assignment of authorized representation [pdf]
  Please complete and submit this form to authorize release of information and to assign an authorized representative.
• Authorization for release of information and assignment of authorized representation - for a minor [pdf]
  Please complete and submit this form to authorize release of information and to assign an authorized representative.
• Continuity of Care form [pdf]
• Dependent application for out-of-area classification [pdf]
  Dependents of active employees that travel, live or work outside of Arkansas for more than 90 days may be eligible for a temporary out-of-area classification.
• Designation for authorized appeal representative form [pdf]
• Health Advantage medical claim form [pdf]
  We want to pay your eligible medical claim as fast as possible, so please complete and submit this form.
• Member appeal submission form [pdf]
  Want to appeal a denied claim? Complete and submit this form with any additional information, and your request will be reviewed.
• Other insurance/Coordination of Benefits (COB) [pdf]
  Do you have other insurance? Fill out this form, and let us know.
• Proof of incapacity of a dependent - Physician's form [pdf]
• Proof of incapacity of a dependent - Policyholder's form [pdf]
• Prescription claim form [pdf]
  To make sure eligible claims are paid quickly, please complete and submit this form.
• Request for confidential communications [pdf]
  You have the right to request that we keep communications with you confidential and communicate in an alternate manner.