Employer Forms

Updated: 10/30/20

Enrollment & Change Forms Purpose
2021 Small Group Enrollment/Change Form Used to submit a change or to enroll an employee in a small group qualified health plan
2021 Small Group: New Group Enrollment PacketSmall groups who are NEW to Blue Cross and Blue Shield of Vermont should complete this packet
Large Group Enrollment/Change Form

Used for employee updates to enrollment

Note: Application forms must be accompanied by a copy of the Summary of Benefits and Coverage (SBC) when provided to an employee enrolling in an employer group plan that has renewed on or after October 1, 2012.
BlueCare Access Enrollment/Change Form

BlueCare Access Enrollment form for subscribers.

Note:  Use this form only if you have BlueCare Access coverage.

Online Group Enrollment FormUsed for new enrollment/hires only.
Other Group Forms Purpose
Broker Authorization Form This form allows employer groups to designate a broker agency and/or individual brokers as authorized contacts to receive or change information on behalf of the group. It will be included in this year's renewal forms that CBSS and account managers review with both small and large groups.
Average Employee Count CalculationMedical Loss Ratio employee count.
Continuity of Care

Members can complete this form electronically through the Member Resource Center (under "My Forms")
For new members receiving treatment for a chronic medical, mental health or substance abuse condition or pregnant and are in their 2nd or 3rd trimester. Completion of this form will ensure a seamless transition of health care and pharmacy needs.

Statement of Domestic Partnership

Domestic Partner Coverage
Group Membership UpdateMembership Changes
Adult Dependent Coverage RequestRequest for coverage, and medical certification
MSP Step-by-Step Guide for Small Group ExceptionStep-by-step guidance on how to apply for a small employer exception from Medicare coordination of benefits contractor.
Waiver of Group Health Insurance Used by spouses or partners to opt-out of Blue Cross and Blue Shield of Vermont coverage

Go to Member Forms

VT Blue 65 (CMS, Credible/Non-Credible Coverage)

Form Purpose
Credibility AnalysisImportant notice concerning prescription drug coverage
Creditable Coverage Simplified DeterminationImportant notice concerning prescription drug coverage
Creditable Notice  (Word Doc)Important notice concerning prescription drug coverage
Non-Creditable Notice  (Word Doc)Important notice concerning prescription drug coverage
CMS Creditable Coverage GuidanceImportant notice concerning prescription drug coverage
Group Subscriber Medicare Supplement ApplicationForm for a group subscriber's changes

 Go to Member Forms