Forms & guides for employers

2024

Small group business application

Enrollment/waiver form — English

Enrollment/waiver form — Spanish

2023

Small group business application

Enrollment/waiver form — English

Enrollment/waiver form — Spanish

General

Authorization for disclosure of health information — Most efficient: Share this online form url with employees: bluecrossmn.com/adhi or download PDF — English

Authorization for disclosure of health information — Hmong

Authorization for disclosure of health information — Spanish

Cancel form for employees or dependents

Small group change form

HIPAA special enrollment notice

Subscriber claim form

Large group HIPAA special enrollment notice

Large group enrollment/waiver form — English

Large group enrollment/waiver form — Spanish

Large group cancelation form — English

Large group cancelation form — Spanish

Medicare Part D creditable letter

Medicare Part D non-creditable letter

COBRA Forms and information

Authorization for disclosure of health information (online form) or download PDF — English

Authorization for disclosure of health information — Hmong

Authorization for disclosure of health information — Spanish

Fully insured plan election form (2024)

Fully insured plan election form (2025)

Self-insured plan election form (2024)

Self-insured plan election form (2025)

Retiree-only group attestation form (2024)

Retiree-only group attestation form (2025)

Employer fully insured group and Medicare group electronic funds transfer form

Employer portal access request form

Grandfathered plan notice

MA HCR filing service

Premium contribution tool (XLS)

• Only for fully insured groups, to determine grandfathered status