Member Forms

Healthy Employees Supported by                                           Quality,  Well-Managed Programs

 

 

BSSP

  New Member Information

 

Application for Enrollment

Certification of Coordination of Benefits

Summary of Benefits for Members with Double Coverage

Explanation re Phantom Coordination of Benefits

Whom Do I Call?

Anthem Blue Cross

Medical Claim Form

Disabled Dependent Certification

Individual Authorization - A form to authorize another person to discuss your claims private health and claims information with an Anthem representative. 

Order of Benefits - A flowchart to be used in determine which coverage is primary

Claim Payment Comparisons - A comparison of how the same set of claims will be paid under each BSSP plan

Individual Conversion Plans - An application to continue benefits under a purchased policy from Anthem Blue Cross when eligibility for coverage through Butte Schools Self-Funded programs is exhausted.

Employee Assistance Plan (EAP) Brochure

Medco

Prescription Claim Reimbursement Form - to request reimbursement for a claim already paid

Medco by Mail Order Form - to request a prescription be filled by mail.  Mail order form address:                                                    Medco Health Solutions of Fort Worth
                                                                 P.O. Box 650022
                                                                 Dallas, TX  75265-0022

Benefit Coverage / Appeal Request

Delta Dental

Dental Claim Form

Vision Service Plan (VSP)

Vision Claim Form

Sun Life Financial

Assist America (Emergency Travel Assistance and Identity Theft Protection)

Optional Life and Voluntary AD&D Enrollment Form

Evidence of Insurability request for spouse and/or employee  (Enter policy no. 201700)

Evidence of Insurability request for spouse, only

Beneficiary Designation

Designacion de Beneficiario

Portability versus Conversion - Which one to choose upon separation from employment?

Portability Notice and Portability Kit

Conversion Notice

Death Claim Packet

Life Benefits Claim Packet

For more information

Christy R. Patterson, Executive Director
Phone: (530) 532-5837
Email: cpatters@bsspjpa.org

Cathy Ramirez, Administrative Assistant
Phone: (530) 532-5838
Email: cramirez@bsspjpa.org

Fax: (530) 532-5836