Applications and Forms - Broker and Agent Services

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

FlexAmerica HRA Application

FlexAmerica HSA Application

BluePreferred - Limited Benefit Plan

Group Application and Enrollment 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 HRA Application

FlexAmerica HSA Application

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 Claim Form

FlexAmerica HRA Application

FlexAmerica HSA Application

CareFirst Regional Dental Freestanding

Group & Member Applications
Authorization Agreement for ACH Debit

DHMO Dental (TDN) Freestanding

Revised Forms Available Soon

Click the link above for more information about MD DHMO Sales.

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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	Serving Maryland, the District of Columbia and portions of Virginia. CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. ®' Registered trademark of CareFirst of Maryland, Inc.
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