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
Employer Request For Contract Change Form
01/01/2018 Download
Employer Application (01.18)
01/01/2018 Download
Employer Application (10.17)
10/01/2017 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
01/01/2018 Download
Small Business Employee Change Request Form
04/01/2017 Download
Small Business Employee Application
01/01/2018 Download
Small Business Employee Application
10/01/2017 Download
Statement of Claim Blue Shield Life
Download
Subscriber's Statement of Claim
Download
Vision Claim
Download
Waiver of Premium Claim Form Group Life
Download
Form Name Effective Date Download Form
2018 Medical HMO Off-Exchange Package
Platinum Access + HMO 0/20 OffEx
01/01/2018 Summary SBC
Platinum Access + HMO 0/25 OffEx
01/01/2018 Summary SBC
Platinum Access + HMO 0/30 OffEx
01/01/2018 Summary SBC
Platinum Local Access + HMO 0/20 OffEx
01/01/2018 Summary SBC
Platinum Local Access + HMO 0/25 OffEx
01/01/2018 Summary SBC
Platinum Local Access + HMO 0/30 OffEx
01/01/2018 Summary SBC
Platinum Trio ACO HMO 0/20 OffEx
01/01/2018 Summary SBC
Platinum Trio ACO HMO 0/25 OffEx
01/01/2018 Summary SBC
Platinum Trio ACO HMO 0/30 OffEx
01/01/2018 Summary SBC
Gold Access + HMO 500/35 OffEx
01/01/2018 Summary SBC
Gold Access + HMO 1700/35 OffEx
01/01/2018 Summary SBC
Gold Local Access + HMO 500/35 OffEx
01/01/2018 Summary SBC
Gold Local Access + HMO 1700/35 OffEx
01/01/2018 Summary SBC
Gold Trio ACO HMO 500/35 OffEx
01/01/2018 Summary SBC
Gold Trio ACO HMO 1700/35 OffEx
01/01/2018 Summary SBC
Silver Access+ HMO 1750/55 OffEx
01/01/2018 Summary SBC
Silver Local Access + HMO 1750/55 OffEx
01/01/2018 Summary SBC
Silver Trio ACO HMO 1750/55 OffEx
01/01/2018 Summary SBC
2018 Medical PPO Off-Exchange Package
Platinum Full PPO 0/10 OffEx
01/01/2018 Summary SBC
Platinum Full PPO 250/15 OffEx
01/01/2018 Summary SBC
Platinum Tandem PPO 0/10 OffEx
01/01/2018 Summary SBC
Platinum Tandem PPO 250/15 OffEx
01/01/2018 Summary SBC
Gold Full PPO 0/20 OffEx
01/01/2018 Summary SBC
Gold Full PPO 450/30 OffEx
01/01/2018 Summary SBC
Gold Full PPO 750/30 OffEx
01/01/2018 Summary SBC
Gold Full PPO 1200/35 OffEx
01/01/2018 Summary SBC
Gold Tandem PPO 750/30 OffEx
01/01/2018 Summary SBC
Silver Full PPO 1700/55 OfEx
01/01/2018 Summary SBC
Silver Full PPO 2000/45 OffEx
01/01/2018 Summary SBC
Silver Full PPO Savings 2000/20% OffEx
01/01/2018 Summary SBC
Silver Tandem PPO 1700/55 OffEx
01/01/2018 Summary SBC
Silver Tandem PPO 2000/45 OffEx
01/01/2018 Summary SBC
Bronze Full PPO 3750/65 OffEx
01/01/2018 Summary SBC
Bronze Full PPO 5700/60 OffEx
01/01/2018 Summary SBC
Bronze Full PPO Savings 4300/40% OffEx
01/01/2018 Summary SBC
Bronze Full PPO Savings 6550 OffEx
01/01/2018 Summary SBC
Bronze Tandem PPO 3750/65 OffEx
01/01/2018 Summary SBC
2018 Medical HMO Mirror Package
Platinum 90 HMO 0/15 Trio + Child Dental
01/01/2018 Summary SBC
Gold 80 HMO 0/25 Trio + Child Dental
01/01/2018 Summary SBC
Silver 70 HMO 2000/45 Trio + Child Dental
01/01/2018 Summary SBC
2018 Medical PPO Mirror Package
Platinum 90 PPO 0/15 + Child Dental
01/01/2018 Summary SBC
Gold 80 PPO 0/25 + Child Dental
01/01/2018 Summary SBC
Silver 70 PPO 2000/45 + Child Dental
01/01/2018 Summary SBC
Bronze 60 PPO 6300/75 + Child Dental
01/01/2018 Summary SBC
2018 Infertility Rider for HMO Plans
01/01/2018 Summary
2018 Infertility Rider for PPO and HSA Plans
01/01/2018 Summary
2018 Medical HMO Off-Exchange Package with Infertility Rider
Platinum Access + HMO 0/20 OffEx INF
01/01/2018 SBC
Platinum Access + HMO 0/25 OffEx INF
01/01/2018 SBC
Platinum Access + HMO 0/30 OffEx INF
01/01/2018 SBC
Platinum Local Access + HMO 0/20 OffEx INF
01/01/2018 SBC
Platinum Local Access + HMO 0/25 OffEx INF
01/01/2018 SBC
Platinum Local Access + HMO 0/30 OffEx INF
01/01/2018 SBC
Platinum Trio ACO HMO 0/20 OffEx INF
01/01/2018 SBC
Platinum Trio ACO HMO 0/25 OffEx INF
01/01/2018 SBC
Platinum Trio ACO HMO 0/30 OffEx INF
01/01/2018 SBC
Gold Access + HMO 500/35 OffEx INF
01/01/2018 SBC
Gold Access + HMO 1700/35 OffEx INF
01/01/2018 SBC
Gold Local Access + HMO 500/35 OffEx INF
01/01/2018 SBC
Gold Local Access + HMO 1700/35 OffEx INF
01/01/2018 SBC
Gold Trio ACO HMO 500/35 OffEx INF
01/01/2018 SBC
Gold Trio ACO HMO 1700/35 OffEx INF
01/01/2018 SBC
Silver Access+ HMO 1750/55 OffEx INF
01/01/2018 SBC
Silver Local Access+HMO 1750/55 OffEx INF
01/01/2018 SBC
Silver Trio ACO HMO 1750/55 OffEx INF
01/01/2018 SBC
2018 Medical PPO Off-Exchange Package with Infertility Rider
Platinum Full PPO 0/10 OffEx INF
01/01/2018 SBC
Platinum Full PPO 250/15 OffEx INF
01/01/2018 SBC
Platinum Tandem PPO 0/10 OffEx INF
01/01/2018 SBC
Platinum Tandem PPO 250/15 OffEx INF
01/01/2018 SBC
Gold Full PPO 0/20 OffEx INF
01/01/2018 SBC
Gold Full PPO 450/30 OffEx INF
01/01/2018 SBC
Gold Full PPO 750/30 OffEx INF
01/01/2018 SBC
Gold Full PPO 1200/35 OffEx INF
01/01/2018 SBC
Gold Tandem PPO 750/30 OffEx INF
01/01/2018 SBC
Silver Full PPO 1700/55 OfEx INF
01/01/2018 SBC
Silver Full PPO 2000/45 OffEx INF
01/01/2018 SBC
Silver Full PPO Savings 2000/20% OffEx INF
01/01/2018 SBC
Silver Tandem PPO 1700/55 OffEx INF
01/01/2018 SBC
Silver Tandem PPO 2000/45 OffEx INF
01/01/2018 SBC
Bronze Full PPO 3750/65 OffEx INF
01/01/2018 SBC
Bronze Full PPO 5700/60 OffEx INF
01/01/2018 SBC
Bronze Full PPO Savings 4300/40% OffEx INF
01/01/2018 SBC
Bronze Full PPO Savings 6550 OffEx INF
01/01/2018 SBC
Bronze Tandem PPO 3750/65 OffEx INF
01/01/2018 SBC
2018 Medical HMO Mirror Package with Infertility Rider
Platinum 90 HMO 0/15 Trio + Child Dental INF
01/01/2018 SBC
Gold 80 HMO 0/25 Trio + Child Dental INF
01/01/2018 SBC
Silver 70 HMO 2000/45 Trio + Child Dental INF
01/01/2018 SBC
2018 Medical PPO MIrror Package with Infertility
Platinum 90 PPO 0/15 + Child Dental INF
01/01/2018 SBC
Gold 80 PPO 0/25 + Child Dental INF
01/01/2018 SBC
Silver 70 PPO 2000/45 + Child Dental INF
01/01/2018 SBC
Bronze 60 PPO 6300/75 + Child Dental INF
01/01/2018 SBC
2017 Medical HMO Off-Exchange Package
Platinum Access + HMO 0/20 OffEx
01/01/2017 SBC
Platinum Access + HMO 0/25 OffEx
01/01/2017 SBC
Platinum Access + HMO 0/30 OffEx
01/01/2017 SBC
Platinum Local Access + HMO 0/20 OffEx
01/01/2017 SBC
Platinum Local Access + HMO 0/25 OffEx
01/01/2017 SBC
Platinum Local Access + HMO 0/30 OffEx
01/01/2017 SBC
Platinum Trio ACO HMO 0/20 OffEx
01/01/2017 SBC
Platinum Trio ACO HMO 0/25 OffEx
01/01/2017 SBC
Platinum Trio ACO HMO 0/30 OffEx
01/01/2017 SBC
Gold Access + HMO 500/35 OffEx
01/01/2017 SBC
Gold Access + HMO 1700/30 OffEx
01/01/2017 SBC
Gold Local Access + HMO 500/35 OffEx
01/01/2017 SBC
Gold Local Access + HMO 1700/30 OffEx
01/01/2017 SBC
Gold Trio ACO HMO 500/35 OffEx
01/01/2017 SBC
Gold Trio ACO HMO 1700/30 OffEx
01/01/2017 SBC
Silver Access+ HMO 1700/55 OffEx
01/01/2017 SBC
Silver Local Access + HMO 1700/55 OffEx
01/01/2017 SBC
Silver Trio ACO HMO 1700/55 OffEx
01/01/2017 SBC
2017 Medical PPO Off-Exchange Package
Platinum Full PPO 0/10 OffEx
01/01/2017 SBC
Platinum Full PPO 150/15 OffEx
01/01/2017 SBC
Gold Full PPO 0/20 OffEx
01/01/2017 SBC
Gold Full PPO 250/30 OffEx
01/01/2017 SBC
Gold Full PPO 750/20 OffEx
01/01/2017 SBC
Gold Full PPO 1000/35 OffEx
01/01/2017 SBC
Silver Full PPO 1300/45 OffEx
01/01/2017 SBC
Silver Full PPO 1700/40 OffEx
01/01/2017 SBC
Silver Full PPO Savings 2000/20% OffEx
01/01/2017 SBC
Bronze Full PPO 3750/65 OffEx
01/01/2017 SBC
Bronze Full PPO 5100/60 OffEx
01/01/2017 SBC
Bronze Full PPO Savings 4700/40% OffEx
01/01/2017 SBC
Bronze Full PPO Savings 5500/40% OffEx
01/01/2017 SBC
2017 Medical HMO Mirror Package
Platinum 90 HMO 0/15 + Child Dental INF
01/01/2017 SBC
Gold 80 HMO 0/30 + Child Dental INF
01/01/2017 SBC
Silver 70 HMO 2000/45 + Child Dental INF
01/01/2017 SBC
2017 Medical PPO Mirror Package
Platinum 90 PPO 0/15 + Child Dental
01/01/2017 SBC
Platinum 90 PPO 0/15 + Child Dental INF
01/01/2017 SBC
Gold 80 PPO 0/30 + Child Dental
01/01/2017 SBC
Gold 80 PPO 0/30 + Child Dental INF
01/01/2017 SBC
Silver 70 PPO 2000/45 + Child Dental
01/01/2017 SBC
Silver 70 PPO 2000/45 + Child Dental INF
01/01/2017 SBC
Bronze 60 PPO 6300/75 + Child Dental
01/01/2017 SBC
Bronze 60 PPO 6300/75 + Child Dental INF
01/01/2017 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
Form Name Effective Date Download Form
Broker Employer Talking Points
Download
Provider Search Flyer
Download
Tandem PPO Broker/Employer Flyer
Download
Tandem PPO Member Flyer
Download
Vaccines at Retail Pharmacies
Download
Form Name Effective Date Download Form
Contact Sheet and Processing Times
Download