Helpful forms for your business

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. Please note: 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
    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
    Application and instructions
  • Request for Amendment to the Sales Agreement
    Use this form only if you are making changes to your plan
  • Small Group Enrollment Guidelines
    For adding and terminating coverage for employees
  • Small Group Member Application (English)
    For medical, dental, and vision insurance
  • Small Group Sales Agreement
    For groups with 50 employees or fewer
  • 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

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

Mail to:
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. Please note: 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
  • Group Dependent Addendum
  • Group Enrollment Checklist
  • 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

  • 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)
  • Request for Extension of Dependent Child Coverage
  • Affidavit of Common Law Marriage
  • Declaration of Domestic Partnership

Other forms you might need

  • Dental coupon for expecting Blue Cross Dental members
    Studies have shown that it’s important for pregnant women to receive regular dental care—that is why pregnant Blue Cross Dental members are eligible for one extra dental cleaning per year with this Dental Coupon.
  • International Claim Form
    This claim form is used when services are rendered outside of United States.
  • Medical Certification Form
  • Member Reimbursement Donor Egg and Sperm
    Complete and submit this form to request reimbursement for this service.
  • Member Reimbursement Oral Enteral Food Products Form
    Complete and submit this form to request reimbursement for these products.

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