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
New Group Submission
New Group Submission Checklist
01/01/2018 Download
Express Enrollment Guidelines
01/01/2018 Download
Employer Application 4.18 and Later Effective
04/01/2018 Download
Eligibility-Participation Attestation (for groups with 10+ enrolling employees)
01/01/2018 Download
Sole Proprietor, Partner, or Corporate Officer Statement
01/01/2018 Download
Small Group Check by Fax Form
01/01/2018 Download
In Force Group Forms
Employer Request For Contract Change Form 4.18 and Later Effective
04/01/2018 Download
Blue Shield Multiple Subscriber Change Spreadsheet
03/01/2018 Download
Employee Cancellation Transmittal Request
01/01/2018 Download
Employer Notification of Qualifying Events under Cal-COBRA
01/01/2018 Download
CMS Reporting Form
01/01/2018 Download
Group Information Update Form
01/01/2018 Download
Administration
2018 Group Administrator's Guide
01/01/2018 Download
Employer Connection Plus QuickStart Guide
01/01/2018 Download
Employer Connection Plus FAQ
01/01/2018 Download
Employer Connection Plus Online Bill Payment FAQ
01/01/2018 Download
Employer Connection Plus Open Enrollment Guide
01/01/2018 Download
Form Name Effective Date Download Form
Enrollment and Change Forms
Small Group Employee Application 4.18 and Later Effective
04/01/2018 Download
Refusal of Coverage Form
01/01/2018 Download
Continuity of Care Program Brochure
01/01/2018 Download
Continuity of Care Services Request Form
01/01/2018 Download
Declaration of Disability for Over-Age Dependent Child
01/01/2018 Download
Prior Carrier Deductible Instructions and Form
01/01/2018 Download
Subscriber Change Request Form 4.18 and Later Effective
04/01/2018 Download
COBRA and Cal-COBRA Forms
COBRA Continuation of Coverage Application
01/01/2018 Download
Continuing Group Coverage After Federal COBRA Cal-COBRA Election Form
01/01/2018 Download
Cal-COBRA Take-Over Form
01/01/2018 Download
Cal-COBRA Election Form
01/01/2018 Download
Cal-COBRA Dental Election Form
01/01/2018 Download
Claim Forms
Authorization for the Use or Disclosure of Health Information
01/01/2018 Download
Medical Claim Form
01/01/2018 Download
Medical Claim Form - Blue Shield Life
01/01/2018 Download
Pharmacy Reimbursement Form
01/01/2018 Download
International Claim Form
01/01/2018 Download
Dental Claim Form
01/01/2018 Download
Vision Claim Form
01/01/2018 Download
Proof of Death Form - Group Life
01/01/2018 Download
Dismemberment Claim Form - Group Life
01/01/2018 Download
Accelerated Death Benefit Claim Form - Group Life
01/01/2018 Download
Waiver of Premium Claim Form - Group Life
01/01/2018 Download
Form Name Effective Date Download Form
2018 Medical HMO Off-Exchange Package
Access+ HMO Network
Platinum Access+ HMO 0/20 OffEx
01/01/2018 Summary SBC
Platinum Access+ HMO 0/20 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Platinum Access+ HMO 0/25 OffEx
01/01/2018 Summary SBC
Platinum Access+ HMO 0/25 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Platinum Access+ HMO 0/30 OffEx
01/01/2018 Summary SBC
Platinum Access+ HMO 0/30 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Gold Access+ HMO 500/35 OffEx
01/01/2018 Summary SBC
Gold Access+ HMO 500/35 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Gold Access+ HMO 1700/35 OffEx
01/01/2018 Summary SBC
Gold Access+ HMO 1700/35 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Silver Access+ HMO 1750/55 OffEx
01/01/2018 Summary SBC
Silver Access+ HMO 1750/55 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Local Access+ HMO Network
Platinum Local Access+ HMO 0/20 OffEx
01/01/2018 Summary SBC
Platinum Local Access+ HMO 0/20 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Platinum Local Access+ HMO 0/25 OffEx
01/01/2018 Summary SBC
Platinum Local Access+ HMO 0/25 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Platinum Local Access+ HMO 0/30 OffEx
01/01/2018 Summary SBC
Platinum Local Access+ HMO 0/30 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Gold Local Access+ HMO 500/35 OffEx
01/01/2018 Summary SBC
Gold Local Access+ HMO 500/35 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Gold Local Access+ HMO 1700/35 OffEx
01/01/2018 Summary SBC
Gold Local Access+ HMO 1700/35 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Silver Local Access+ HMO 1750/55 OffEx
01/01/2018 Summary SBC
Silver Local Access+ HMO 1750/55 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Trio HMO Network
Platinum Trio HMO 0/20 OffEx
01/01/2018 Summary SBC
Platinum Trio HMO 0/20 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Platinum Trio HMO 0/25 OffEx
01/01/2018 Summary SBC
Platinum Trio HMO 0/25 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Platinum Trio HMO 0/30 OffEx
01/01/2018 Summary SBC
Platinum Trio HMO 0/30 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Gold Trio HMO 500/35 OffEx
01/01/2018 Summary SBC
Gold Trio HMO 500/35 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Gold Trio HMO 1700/35 OffEx
01/01/2018 Summary SBC
Gold Trio HMO 1700/35 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Silver Trio HMO 1750/55 OffEx
01/01/2018 Summary SBC
Silver Trio HMO 1750/55 OffEx INF (with Infertility Rider)
01/01/2018 SBC
2018 Medical PPO Off-Exchange Package
Full PPO Network
Platinum Full PPO 0/10 OffEx
01/01/2018 Summary SBC
Platinum Full PPO 0/10 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Platinum Full PPO 250/15 OffEx
01/01/2018 Summary SBC
Platinum Full PPO 250/15 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Gold Full PPO 0/20 OffEx
01/01/2018 Summary SBC
Gold Full PPO 0/20 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Gold Full PPO 450/30 OffEx
01/01/2018 Summary SBC
Gold Full PPO 450/30 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Gold Full PPO 750/30 OffEx
01/01/2018 Summary SBC
Gold Full PPO 750/30 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Gold Full PPO 1200/35 OffEx
01/01/2018 Summary SBC
Gold Full PPO 1200/35 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Silver Full PPO 1700/55 OfEx
01/01/2018 Summary SBC
Silver Full PPO 1700/55 OfEx INF (with Infertility Rider)
01/01/2018 SBC
Silver Full PPO 2000/45 OffEx
01/01/2018 Summary SBC
Silver Full PPO 2000/45 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Silver Full PPO Savings 2000/20% OffEx
01/01/2018 Summary SBC
Silver Full PPO Savings 2000/20% OffEx INF (with Infertility Rider)
01/01/2018 SBC
Bronze Full PPO 3750/65 OffEx
01/01/2018 Summary SBC
Bronze Full PPO 3750/65 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Bronze Full PPO 5700/60 OffEx
01/01/2018 Summary SBC
Bronze Full PPO 5700/60 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Bronze Full PPO Savings 4300/40% OffEx
01/01/2018 Summary SBC
Bronze Full PPO Savings 4300/40% OffEx INF (with Infertility Rider)
01/01/2018 SBC
Bronze Full PPO Savings 6550 OffEx
01/01/2018 Summary SBC
Bronze Full PPO Savings 6550 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Tandem PPO Network
Platinum Tandem PPO 0/10 OffEx
01/01/2018 Summary SBC
Platinum Tandem PPO 0/10 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Platinum Tandem PPO 250/15 OffEx
01/01/2018 Summary SBC
Platinum Tandem PPO 250/15 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Gold Tandem PPO 750/30 OffEx
01/01/2018 Summary SBC
Gold Tandem PPO 750/30 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Silver Tandem PPO 1700/55 OffEx
01/01/2018 Summary SBC
Silver Tandem PPO 1700/55 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Silver Tandem PPO 2000/45 OffEx
01/01/2018 Summary SBC
Silver Tandem PPO 2000/45 OffEx INF (with Infertility Rider)
01/01/2018 SBC
Bronze Tandem PPO 3750/65 OffEx
01/01/2018 Summary SBC
Bronze Tandem PPO 3750/65 OffEx INF (with Infertility Rider)
01/01/2018 SBC
2018 Medical HMO Mirror Package
Platinum 90 HMO 0/15 Trio + Child Dental
01/01/2018 Summary SBC
Platinum 90 HMO 0/15 Trio + Child Dental INF (with Infertility Rider)
01/01/2018 SBC
Gold 80 HMO 0/25 Trio + Child Dental
01/01/2018 Summary SBC
Gold 80 HMO 0/25 Trio + Child Dental INF (with Infertility Rider)
01/01/2018 SBC
Silver 70 HMO 2000/45 Trio + Child Dental
01/01/2018 Summary SBC
Silver 70 HMO 2000/45 Trio + Child Dental INF (with Infertility Rider)
01/01/2018 SBC
2018 Medical PPO Mirror Package
Platinum 90 PPO 0/15 + Child Dental
01/01/2018 Summary SBC
Platinum 90 PPO 0/15 + Child Dental INF (with Infertility Rider)
01/01/2018 SBC
Gold 80 PPO 0/25 + Child Dental
01/01/2018 Summary SBC
Gold 80 PPO 0/25 + Child Dental INF (with Infertility Rider)
01/01/2018 SBC
Silver 70 PPO 2000/45 + Child Dental
01/01/2018 Summary SBC
Silver 70 PPO 2000/45 + Child Dental INF (with Infertility Rider)
01/01/2018 SBC
Bronze 60 PPO 6300/75 + Child Dental
01/01/2018 Summary SBC
Bronze 60 PPO 6300/75 + Child Dental INF (with Infertility Rider)
01/01/2018 SBC
2018 Infertility Riders
Infertility Rider for HMO Plans
01/01/2018 Summary
Infertility Rider for PPO and HSA Plans
01/01/2018 Summary
2018 Disclosures
HMO Plans for Small Business Disclosure
01/01/2018 Summary
PPO Plans for Small Business Disclosure
01/01/2018 Summary
PPO Savings (HSA) Plans for Small Business Disclosure
01/01/2018 Summary
2017 Medical HMO Off-Exchange Package
Access+ HMO Network
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
Gold Access+ HMO 500/35 OffEx
01/01/2017 SBC
Gold Access+ HMO 1700/30 OffEx
01/01/2017 SBC
Silver Access+ HMO 1700/55 OffEx
01/01/2017 SBC
Local Access+ HMO Network
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
Gold Local Access+ HMO 500/35 OffEx
01/01/2017 SBC
Gold Local Access+ HMO 1700/30 OffEx
01/01/2017 SBC
Silver Local Access+ HMO 1700/55 OffEx
01/01/2017 SBC
Trio ACO HMO Network
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 Trio ACO HMO 500/35 OffEx
01/01/2017 SBC
Gold Trio ACO HMO 1700/30 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
General Information
Blue Shield Sales Guide 1.18 - 3.18 Effective
01/01/2018 Download
Blue Shield Sales Guide 4.18 and Later Effective
04/01/2018 Download
Blue Shield - Insurance Industry Glossary
01/01/2018 Download
How to Access Your Benefits Online
01/01/2018 Download
Online and Mobile Tools
01/01/2018 Download
Relaxed Participation Guidelines through 9.18 Effective
01/01/2018 Download
Small Group Underwriting Guidelines 1.18 to 3.18 Effective
01/01/2018 Download
Small Group Underwriting Guidelines 4.18 and Later Effective
04/01/2018 Download
What's New for Small Group Q1 2018
01/01/2018 Download
What's New for Small Group Q2 2018
04/01/2018 Download
Why Blue Shield of California
01/01/2018 Download
Medical
Access to Care Flyer
01/01/2018 Download
Away from Home Care for HMO Members
01/01/2018 Download
Blue Card Program for Care Outside California for PPO Members
01/01/2018 Download
Blue Shield Network Guide
01/01/2018 Download
Easy Steps to Print or Order your ID Card
01/01/2018 Download
Epic Hearing Discounts
01/01/2018 Download
Heal Physician Flyer for PPO Members
01/01/2018 Download
MailOrder Rx Flyer
01/01/2018 Download
Member Discount Programs
01/01/2018 Download
NurseHelp Employee Flyer
01/01/2018 Download
NurseHelp Employer Brochure
01/01/2018 Download
Pediatric Dental & Vision FAQ
01/01/2018 Download
Pediatric Dental & Vision Infographic
01/01/2018 Download
Preventive Health Guidelines
01/01/2018 Download
Provider Search Instructions
01/01/2018 Download
Shield Concierge for Trio Members
01/01/2018 Download
Tandem PPO Broker/Employer Flyer
01/01/2018 Download
Tandem PPO Member Flyer
01/01/2018 Download
Teladoc Flyer
01/01/2018 Download
Treatment Cost Estimator PPO Member Flyer
01/01/2018 Download
Treatment Cost Estimator Step by Step for PPO Members
01/01/2018 Download
Trio HMO Brochure
01/01/2018 Download
Trio HMO Conversion Brochure
01/01/2018 Download
Trio HMO Walkadoo Flyer
01/01/2018 Download
Trio Network Guide
01/01/2018 Download
Trio Prenatal Care Flyer
01/01/2018 Download
Trio Qualification Tool
01/01/2018 Download
Urgent Care Flyer
01/01/2018 Download
Vaccines at Retail Pharmacies
01/01/2018 Download
Wellvolution flyer
01/01/2018 Download
Dental
Broker Dental Brochure
01/01/2018 Download
Broker Specialty Bundling Flyer
01/01/2018 Download
Caries Risk Management & Assessment
01/01/2018 Download
Dental Competitive Highlight Sheet
01/01/2018 Download
Dental Implant FAQ
01/01/2018 Download
Dental Network Map
01/01/2018 Download
Dental Smile Rollover Rewards Program
01/01/2018 Download
Dentist Nomination Form
01/01/2018 Download
Guide to Managing your Dental Plan Online
01/01/2018 Download
Member Guide to Orthodontic Coverage
01/01/2018 Download
Vision
Broker Vision Brochure
01/01/2018 Download
Managing Your Vision Plan Online
01/01/2018 Download
Vision Network at a Glance
01/01/2018 Download
Vision Plan Information Card for CA Members
01/01/2018 Download
Life
Broker Life Brochure
01/01/2018 Download
Basic Life/AD&D Quick Match Program Guidelines
03/01/2018 Download
Form Name Effective Date Download Form
Contact Sheet and Processing Times
Download
Blue Shield Contact Information for Employees
01/01/2018 Download