Helpful forms for your business

Looking for the Group Activity Report (GAR)?

Find it here or download PDF.

Small Group (50 or fewer employees)

If you qualify as a small group, the following forms will help you manage your BCBSRI plan.

  • Electronic Enrollment Authorization Form
    To authorize the administrator to conduct enrollment for your account
  • Electronic Payment Option Form
    To have your group's monthly premium payment electronically deducted from your group's checking account. Tenga en cuenta: The electronic payment option is only available to groups purchasing health and/or dental coverage directly with BCBSRI. If you purchased coverage through HealthSource RI, please call 1-855-651-7873 for information about payment options.
  • Group Activity Report (GAR) and Instructions (PDF Version)
    To enroll new subscribers, cancel coverage for subscribers, process changes in family status (such as the birth of a child or marriage), or to change plan coverage
  • Group Dependent Addendum
    To add more dependents with a Group Member Application
  • Group Enrollment Checklist
    Keep track of each part of the process
  • Group Plan 65 Member Application
  • Small Group Enrollment Guidelines
    For adding and terminating coverage for employees
  • Small Group Member Application (English)
    For medical, dental, and vision insurance
  • Small Employer Waiver Form/Certification
    For employees who do not want coverage through their employer
  • Small Group Domestic Partner Coverage Offering Election Form

Renewal certification

To start the recertification process, you must complete the Renewal Certification form and return it to Blue Cross with your supporting payroll tax documentation and waivers.

  • Recertification Checklist
    A handy list to help you make sure you’ve got everything you need
  • Initial Letter Attestation
    This explains the importance of returning the attestation form (below)
  • Small Employer Attestation Form
  • Letter Regarding Certification
    This explains the importance of recertification
  • Renewal Certification Form

The documents below are examples of commonly used proof of ownership and payroll documents.

  • Quarterly Tax and Wage Report
  • Schedule C (Form 1040)
  • Schedule K-1 (Form 1120s)
  • Schedule K-1 (Form 1065)
  • W-4 Form

Email to:
recertification@bcbsri.org

Fax to:
Small Group Underwriting - Recertification Unit at (401) 459-5445

Envíelo por correo a:
Blue Cross & Blue Shield of Rhode Island
Small Group Underwriting Recertification Unit
500 Exchange Street, Providence, RI 02903

Large Group (more than 50 employees)

If you qualify as a large group, the following forms will help you manage your BCBSRI plan.

  • Electronic Enrollment Authorization Form
  • Electronic Payment Option Form
    To have your group's monthly premium payment electronically deducted from your group's checking account. Tenga en cuenta: The Electronic Payment Option is only available to groups purchasing health and/or dental coverage directly with BCBSRI. If you purchased coverage through HealthSource RI, please call 1-855-651-7873 for information about payment options.
  • Group Activity Report (GAR) and Instructions (PDF Version)
  • Group Dependent Addendum
  • Group Plan 65 Member Application
  • Large Group Enrollment Guidelines
  • Large Group Member Application (English)
  • BCBSRI Insured Large Group Domestic Partner Coverage Offering Election Form

Self-Funded Employers

  • Plan Sponsor Manual for Self-Funded Clients
  • BCBSRI Self Funded Group Domestic Partner Coverage Offering Election Form
  • Finance Intake Form
  • Retroactive Enrollment Exception Form

Forms for employees

  • PCP Selection Form
    Each member should choose a primary care provider (PCP)
  • Affidavit of Common Law Marriage
  • Declaration of Domestic Partnership

Otros formularios que podría necesitar

  • Formulario de reclamos internacionales
    This claim form is used when services are rendered outside of United States.
  • Reembolso para miembros donantes de óvulos y esperma
    Complete and submit this form to request reimbursement for this service.
  • Formulario de reembolso para miembros por productos de alimentación enteral por vía oral
    Complete and submit this form to request reimbursement for these products.
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