Blue Shield of California

As a not-for-profit health plan, Blue Shield is guided by our mission and values, which encourage innovation and enable us to be a catalyst for constructive change. Our mission and values are embodied in our proposal to guarantee health coverage for all Californians, the first time a major health plan has called for universal coverage.

Provider Finder

Form Name Effective Date Download Form
Eligibility Participation Attestation
01/01/2017 Download
Employer Notification of Qualifying Events under Cal-COBRA
Download
New Group Submission Checklist
01/01/2017 Download
Small Group Check by Fax
01/01/2017 Download
Small Business Master Group Application
04/01/2017 Download
Small Business Master Group Application
01/01/2017 Download
Sole Propritor, Partner, or Corporate Officer Statement
Download
Form Name Effective Date Download Form
Blue Shield Authorization for Release of Personal and Health Information
Download
Blue Card World Wide International Claim
Download
Cal-COBRA Dental Election
Download
Cal-COBRA Election
Download
Cal-COBRA Take-Over
Download
COBRA Employee Application
Download
Continuing Group Coverage After Federal COBRA Cal-COBRA Election
Download
Continuing Group Coverage After Federal COBRA Cal-COBRA Election
Download
Dental Claim
Download
Dismemberment Claim Form Group Life
Download
Member Appeals Grievance
Download
Proof of Death Form Group Life
Download
Small Business Employee Change Request Form
04/01/2017 Download
Small Business Employee Change Request Form
01/01/2017 Download
Small Business Employee Enrollment Form
04/01/2017 Download
Small Business Employee Enrollment Form
01/01/2017 Download
Statement of Claim Blue Shield Life
Download
Subscriber's Statement of Claim
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Vision Claim
Download
Waiver of Premium Claim Form Group Life
Download
Form Name Effective Date Download Form
Medical HMO
Platinum Access + HMO 0/20 OffEx
04/01/2017 SBC
Platinum Access + HMO 0/20 OffEx
01/01/2017 Summary SBC
Platinum Access + HMO 0/25 OffEx
04/01/2017 SBC
Platinum Access + HMO 0/25 OffEx
01/01/2017 Summary SBC
Platinum Access + HMO 0/30 OffEx
04/01/2017 SBC
Platinum Access + HMO 0/30 OffEx
01/01/2017 Summary SBC
Platinum Local Access + HMO 0/20 OffEx
04/01/2017 SBC
Platinum Local Access + HMO 0/20 OffEx
01/01/2017 Summary SBC
Platinum Local Access + HMO 0/25 OffEx
04/01/2017 SBC
Platinum Local Access + HMO 0/25 OffEx
01/01/2017 Summary SBC
Platinum Local Access + HMO 0/30 OffEx
04/01/2017 SBC
Platinum Local Access + HMO 0/30 OffEx
01/01/2017 Summary SBC
Platinum Trio ACO HMO 0/20 OffEx
04/01/2017 SBC
Platinum Trio ACO HMO 0/20 OffEx
01/01/2017 Summary SBC
Platinum Trio ACO HMO 0/25 OffEx
04/01/2017 SBC
Platinum Trio ACO HMO 0/25 OffEx
01/01/2017 Summary SBC
Platinum Trio ACO HMO 0/30 OffEx
04/01/2017 SBC
Platinum Trio ACO HMO 0/30 OffEx
01/01/2017 Summary SBC
Gold Access + HMO 500/35 OffEx
04/01/2017 SBC
Gold Access + HMO 500/35 OffEx
01/01/2017 Summary SBC
Gold Access + HMO 1700/30 OffEx
04/01/2017 SBC
Gold Access + HMO 1700/30 OffEx
01/01/2017 Summary SBC
Gold Local Access + HMO 500/35 OffEx
04/01/2017 SBC
Gold Local Access + HMO 500/35 OffEx
01/01/2017 Summary SBC
Gold Local Access + HMO 1700/30 OffEx
04/01/2017 SBC
Gold Local Access + HMO 1700/30 OffEx
01/01/2017 Summary SBC
Gold Tri ACO HMO 500/35 OffEx
04/01/2017 SBC
Gold Tri ACO HMO 500/35 OffEx
01/01/2017 Summary SBC
Gold Trio ACO HMO 1700/30 OffEx
04/01/2017 SBC
Gold Trio ACO HMO 1700/30 OffEx
01/01/2017 Summary SBC
Silver Access+ HMO 1700/55 OffEx
04/01/2017 SBC
Silver Access+ HMO 1700/55 OffEx
01/01/2017 Summary SBC
Silver Local Access + HMO 1700/55 OffEx
04/01/2017 SBC
Silver Local Access + HMO 1700/55 OffEx
01/01/2017 Summary SBC
Silver Trio ACO HMO 1700/55 OffEx
04/01/2017 SBC
Silver Trio ACO HMO 1700/55 OffEx
01/01/2017 Summary SBC
Medical HMO - Mirrored Plans
Platinum 90 HMO 0/15 + Child Dental INF
04/01/2017 SBC
Platinum 90 HMO 0/15 + Child Dental INF
01/01/2017 Summary SBC
Gold 80 HMO 0/30 + Child Dental INF
04/01/2017 SBC
Gold 80 HMO 0/30 + Child Dental INF
01/01/2017 Summary SBC
Silver 70 HMO 2000/45 + Child Dental INF
04/01/2017 SBC
Silver 70 HMO 2000/45 + Child Dental INF
01/01/2017 Summary SBC
Medical PPO
Platinum Full PPO 0/10 OffEx
04/01/2017 SBC
Platinum Full PPO 0/10 OffEx
01/01/2017 Summary SBC
Platinum Full PPO 150/15 OffEx
04/01/2017 SBC
Platinum Full PPO 150/15 OffEx
01/01/2017 Summary SBC
Gold Full PPO 0/20 OffEx
04/01/2017 SBC
Gold Full PPO 0/20 OffEx
01/01/2017 Summary SBC
Gold Full PPO 250/30 OffEx
04/01/2017 SBC
Gold Full PPO 250/30 OffEx
01/01/2017 Summary SBC
Gold Full PPO 750/20 OffEx
04/01/2017 SBC
Gold Full PPO 750/20 OffEx
01/01/2017 Summary SBC
Gold Full PPO 1000/35 OffEx
04/01/2017 SBC
Gold Full PPO 1000/35 OffEx
01/01/2017 Summary SBC
Silver Full PPO 1300/45 OffEx
04/01/2017 SBC
Silver Full PPO 1300/45 OffEx
01/01/2017 Summary SBC
Silver Full PPO 1700/40 OffEx
04/01/2017 SBC
Silver Full PPO 1700/40 OffEx
01/01/2017 Summary SBC
Silver Full PPO Savings 2000/20% OffEx
04/01/2017 SBC
Silver Full PPO Savings 2000/20% OffEx
01/01/2017 Summary SBC
Bronze Full PPO 3750/65 OffEx
04/01/2017 SBC
Bronze Full PPO 3750/65 OffEx
01/01/2017 Summary SBC
Bronze Full PPO 5100/60 OffEx
04/01/2017 SBC
Bronze Full PPO 5100/60 OffEx
01/01/2017 Summary SBC
Bronze Full PPO Savings 4700/40% OffEx
04/01/2017 SBC
Bronze Full PPO Savings 4700/40% OffEx
01/01/2017 Summary SBC
Bronze Full PPO Savings 5500/40% OffEx
04/01/2017 SBC
Bronze Full PPO Savings 5500/40% OffEx
01/01/2017 Summary SBC
Medical PPO -Mirrored Plans
Platinum 90 PPO 0/15 + Child Dental
04/01/2017 SBC
Platinum 90 PPO 0/15 + Child Dental
01/01/2017 Summary SBC
Gold 80 PPO 0/30 + Child Dental
04/01/2017 SBC
Gold 80 PPO 0/30 + Child Dental
01/01/2017 Summary SBC
Silver 70 PPO 2000/45 + Child Dental
04/01/2017 SBC
Silver 70 PPO 2000/45 + Child Dental
01/01/2017 Summary SBC
Bronze 60 PPO 6300/75 + Child Dental
SBC
Bronze 60 PPO 6300/75 + Child Dental
01/01/2017 Summary SBC
Dental
Dental HMO Basic
Summary
Dental HMO Deluxe
Summary
Dental HMO Plus
Summary
Dental HMO Voluntary
Summary
DPPO Smile 50/1500/No Ortho/MAC
Summary
DPPO Smile Basic 75/1000/No Ortho/MAC
Summary
DPPO Smile Basic Voluntary 75/1000/No Ortho/MAC
Summary
DPPO Smile Deluxe 2000 50/2000/No Ortho/MAC
Summary
DPPO Smile Deluxe 50/1500 Ortho/MAC
Summary
DPPO Smile Deluxe Gold 50/1500 Ortho/U85
Summary
DPPO Smile Deluxe Plus 2000 50/2000 Ortho/MAC
Summary
DPPO Smile Plus 50/1500 Ortho/MAC
Summary
DPPO Smile Plus Gold 50/1500 Ortho/U85
Summary
DPPO Smile Value 50/1500/No Ortho/MAC
Summary
Smile INO Dental PLan 50/1500/Endo-Perio 80%/No Ortho
Summary
Smile INO Dental Plan 50/1500/Endo-Perio 80%/Ortho
Summary
Smile INO Dental Plan 50/2500 Endo-Perio 80%/No Ortho
Summary
Smile INO Dental Plan 50/2500 Endo-Perio 80%/Ortho
Summary
Smile INO Dental Voluntary Plan 50/1500 Endo-Perio 50%/No Ortho
Summary
Smile INO Dental Voluntary Plan 50/1500 Endo-Perio 50%/Ortho
Summary
Smile INO Dental Voluntary Plan 50/2500 Endo-Perio 50%/No Ortho
Summary
Smile INO Dental Voluntary Plan 50/2500 Endo-Perio 50%/Ortho
Summary
Ultimate Dental Plus PPO for Small Business 50/2000
Summary
Ultimate Dental PPO for Small Business 50/2000
Summary
Vision
Enhanced Vision 00/1200
Summary
Enhanced Vision 00/150
Summary
Enhanced Vision 15/25/120
Summary
Enhanced Vision 15/25/150
Summary
Enhanced Vision Plus 00/150/120
Summary
Enhanced Vision Plus 15/25/150/120
Summary
Enhanced Vision Voluntary 15/25/120
Summary
Preferred Vision 00/120
Summary
Preferred Vision 00/150
Summary
Preferred Vision 15/25/120
Summary
Preferred Vision 15/25/150
Summary
Preferred Vision Plus 00/150/120
Summary
Preferred Vision Plus 15/25/150/120
Summary
Preferred Vision Voluntary 15/25/120
Summary
Ultimate Vision 00/120
Summary
Ultimate Vision 00/150
Summary
Ultimate Vision 15/25/120
Summary
Ultimate Vision 15/25/150
Summary
Ultimate Vision Plus 00/150/120
Summary
Ultimate Vision Plus 15/25/150/120
Summary
Ultimate Vision Voluntary 15/25/150
Summary
Life
Group Life and AD&A Insurance $15,000
Summary
Group Life and AD&A Insurance $20,000
Summary
Group Life and AD&A Insurance $25,000
Summary
Group Life and AD&A Insurance $30,000
Summary
Group Life and AD&A Insurance $50,000
Summary
Group Life and AD&A Insurance $75,000
Summary
Group Life and AD&A Insurance $100,000
Summary
Form Name Effective Date Download Form
Broker Employer Talking Points
Download
Basic Life Brochure
Download
Bundle Savings - 5% Discount Flyer
Download
Dental Brochure for Brokers
Download
Dental Highlight Sheet
Download
Dental Implant Benefits FAQs
Download
Dental Network Map
Download
Dental Smile Rollover Rewards Program
Download
Discount Flyer
Download
Generic Vision ID card
Download
Guide to Managing Your Dental Plan Online
Download
How to Find a Dental or Vision Provider
Download
How to Find a Provider
Download
How to Print/ Order ID card
Download
How to Register Online
Download
Identity Theft flyer
Download
Mobile App Flyer
Download
Network Guide
01/01/2017 Download
Nurse Help 24-7 Information Sheet for Employers
Download
Nurse Help 24-7 Information
Download
Pediatric Dental and Vision FAQs
Download
Preventative Health Flyer
Download
Preventative Health Guidelines
Download
Quick Match Small Business Flyer
Download
Rates Orange & San Diego
04/01/2017 Download
Rates Orange & San Diego
01/01/2017 Download
Form Name Effective Date Download Form
Contact Sheet and Processing Times
Download