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
Medical HMO
Platinum Access + HMO 0/20 OffEx INF
01/01/2018 SBC
Platinum Access + HMO 0/20 OffEx
01/01/2018 Summary SBC
Platinum Access + HMO 0/20 OffEx
04/01/2017 SBC
Platinum Access + HMO 0/20 OffEx
01/01/2017 Summary SBC
Platinum Access + HMO 0/20 OffEx INF
01/01/2018 SBC
Platinum Access + HMO 0/25 OffEx
01/01/2018 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 INF
01/01/2018 SBC
Platinum Access + HMO 0/30 OffEx
01/01/2018 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 INF
01/01/2018 SBC
Platinum Local Access + HMO 0/20 OffEx
01/01/2018 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 INF
01/01/2018 SBC
Platinum Local Access + HMO 0/25 OffEx
01/01/2018 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 INF
01/01/2018 SBC
Platinum Local Access + HMO 0/30 OffEx
01/01/2018 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 INF
01/01/2018 SBC
Platinum Trio ACO HMO 0/20 OffEx
01/01/2018 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 INF
01/01/2018 SBC
Platinum Trio ACO HMO 0/25 OffEx
01/01/2018 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 INF
01/01/2018 SBC
Platinum Trio ACO HMO 0/30 OffEx
01/01/2018 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 INF
01/01/2018 SBC
Gold Access + HMO 500/35 OffEx
01/01/2018 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 1700/35 OffEx INF
01/01/2018 SBC
Gold Access + HMO 1700/35 OffEx
01/01/2018 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 INF
01/01/2018 SBC
Gold Local Access + HMO 500/35 OffEx
01/01/2018 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 1700/35 OffEx INF
01/01/2018 SBC
Gold Local Access + HMO 1700/35 OffEx
01/01/2018 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 INF
01/01/2018 SBC
Gold Tri ACO HMO 500/35 OffEx
01/01/2018 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 1700/35 OffEx INF
01/01/2018 SBC
Gold Trio ACO HMO 1700/35 OffEx
01/01/2018 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 1750/55 OffEx INF
01/01/2018 SBC
Silver Access+ HMO 1750/55 OffEx
01/01/2018 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 1750/55 OffEx INF
01/01/2018 SBC
Silver Local Access + HMO 1750/55 OffEx
01/01/2018 Summary SBC
Silver Local Access + HMO 1700/55 OffEx
01/01/2017 Summary SBC
Silver Trio ACO HMO 1750/55 OffEx INF
01/01/2018 SBC
Silver Trio ACO HMO 1750/55 OffEx
01/01/2018 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 Trio + Child Dental INF
01/01/2018 SBC
Platinum 90 HMO 0/15 Trio + Child Dental
01/01/2018 Summary SBC
Platinum 90 HMO 0/15 + Child Dental INF
01/01/2018 SBC
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 0/25 Trio + Child Dental INF
01/01/2018 SBC
Gold 80 HMO 0/25 Trio + Child Dental
01/01/2018 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 Trio + Child Dental INF
01/01/2018 SBC
Silver 70 HMO 2000/45 Trio + Child Dental
01/01/2018 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 INF
01/01/2018 SBC
Platinum Full PPO 0/10 OffEx
01/01/2018 Summary SBC
Platinum Full PPO 0/10 OffEx
04/01/2017 SBC
Platinum Full PPO 0/10 OffEx
01/01/2017 Summary SBC
Platinum Full PPO 250/15 OffEx INF
01/01/2018 SBC
Platinum Full PPO 250/15 OffEx
01/01/2018 Summary SBC
Platinum Full PPO 150/15 OffEx
04/01/2017 SBC
Platinum Full PPO 150/15 OffEx
01/01/2017 Summary SBC
Platinum Tandem PPO 250/15 OffEx INF
01/01/2018 SBC
Platinum Tandem PPO 250/15 OffEx
01/01/2018 Summary SBC
Platinum Tandem PPO 0/10 OffEx INF
01/01/2018 SBC
Platinum Tandem PPO 0/10 OffEx
01/01/2018 Summary SBC
Gold Full PPO 0/20 OffEx INF
01/01/2018 SBC
Gold Full PPO 0/20 OffEx
01/01/2018 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 450/30 OffEx INF
01/01/2018 SBC
Gold Full PPO 450/30 OffEx
01/01/2018 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 750/30 OffEx INF
01/01/2018 SBC
Gold Full PPO 750/30 OffEx
01/01/2018 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 1200/35 OffEx INF
01/01/2018 SBC
Gold Full PPO 1200/35 OffEx
01/01/2018 Summary SBC
Gold Full PPO 1000/35 OffEx
04/01/2017 SBC
Gold Full PPO 1000/35 OffEx
01/01/2017 Summary SBC
Gold Tandem PPO 750/30 OffEx INF
01/01/2018 SBC
Gold Tandem PPO 750/30 OffEx
01/01/2018 Summary SBC
Silver Full PPO 2000/45 OffEx INF
01/01/2018 SBC
Silver Full PPO 2000/45 OffEx
01/01/2018 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 1700/55 OfEx INF
01/01/2018 SBC
Silver Full PPO 1700/55 OfEx
01/01/2018 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 INF
01/01/2018 SBC
Silver Full PPO Savings 2000/20% OffEx
01/01/2018 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
Silver Tamdem PPO 2000/45 OffEx INF
01/01/2018 SBC
Silver Tamdem PPO 2000/45 OffEx
01/01/2018 Summary SBC
Silver Tandem PPO 1700/55 OffEx INF
01/01/2018 SBC
Silver Tandem PPO 1700/55 OffEx
01/01/2018 Summary SBC
Bronze Full PPO 3750/65 OffEx INF
01/01/2018 SBC
Form Name Effective Date Download Form
Broker Employer Talking Points
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Provider Search Flyer
Download
Tandem PPO Broker/Employer Flyer
Download
Tandem PPO Member Flyer
Download
Form Name Effective Date Download Form
Contact Sheet and Processing Times
Download