Individual Forms Request

To order supplies, please fill out the following form completely. Incomplete or missing information could cause a delay in receiving your supplies. Should you have any questions, please contact your Broker Service Representative at 1.800.222.0524. Thank you for your order.

Please discard any forms/brochures with revision dates prior to those received with this order.

Producer Information

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First/Last Name

Producer Number

Street Address 1

Street Address 2

City/State/ZIP

Phone/Fax Number

Email/Confirm Email

Applications - BCBSLA/HMO LA

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01MK5314 Application for Individual Health Coverage

23XX2461 BlueChoice 65 Application Booklet

Applications Attachments

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23XX0350 BCBSLA Individual Health Change of Status Card

23XX7478 BCBSLA List Bill Agreement to Provide Payroll Deduction Services

23XX7480 BCBSLA List Bill Authorization for Payroll Deduction (carbon)

23XX7479 BCBSLA List Bill Disclosure Statement

23XX1938 BCBSLA Prior Carrier Health Coverage Form

23XX2037 Variable Income Plan Disclosure Notice

Brochures

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01MK4375 Blue 365

01MK4872 Blue Connect

01MK5331 Blue Cross Multi-State Plan Brochure

01MK5878 Blue Dental Certified

01MK5877 Blue Dental Traditional

23XX2446 BlueChoice 65 Brochure

23XX2475 BlueChoice 65 Outline of Medicare Supplement Coverage

01 MK 1453 BlueSaver PPO Insert

23XX1628 Cancer and Serious Disease Brochure

01100 01236 Community Blue

01MK4458 Dental Flyer

23XX1849 Guide to Health Insurance for People with Medicare

01MK4558 Individual Solutions Brochure

23XX4119 VIP(Variable Income Plan) Brochure

Other Commonly Used Forms

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23XX1861 Affidavit Acknowledging Insurance Acceptance

01EN1593 Attn: Individual Marketing Support Envelopes

06AC0019 BCBSLA/HMO LA Authorization to Draw Check on My Account

23XX1936 Diabetic Questionnaire

01EN1594 Envelope (Yellow Mem Bill)

23XX6537 Health Insurance Claim Form

23XX5551 High Blood Pressure Report

01MK1763 Medical Guide Questionnaire

23XX5543 Physical Examination Report

23XX4157 Prescription Drug Claim Form

23XX1899 Supplemental Medical History

23XX0261 Supply Fax Order Form

23XX0808 VIP Claim Form

Provider Directories - BCBSLA

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23XX2665 BlueChoice 65 Select Member Hospitals by Parish

00000 PPO Alexandria

00000 PPO Baton Rouge

00000 PPO Lafayette

00000 PPO Lake Charles

00000 PPO Monroe

00000 PPO New Orleans

00000 PPO Shreveport

Provider Directories - HMO LA

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00000 Blue Connect

01100 01203 Community Blue

01100 01204 Community Blue Pharmacy Directory

00000 HMO Baton Rouge

00000 HMO New Orleans

00000 HMO Shreveport

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Customer Service

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855-343-0361

Medicare Options

800-232-4967

Producer Information

Applications - BCBSLA/HMO LA

Applications Attachments

Brochures

Other Commonly Used Forms

Provider Directories - BCBSLA

Provider Directories - HMO LA