Individual Forms Request

To order supplies, please fill out the following form completely. Incomplete or missing information could cause a delay in receiving your supplies. Should you have any questions, please contact your Broker Service Representative at 1.800.222.0524. Thank you for your order.

Please discard any forms/brochures with revision dates prior to those received with this order.

* indicates required field
First Name
Last Name
Producer Number
Street Address
Include apartment, suite number, OR PO Box, if applicable
Zip Code

E-mail Address

Confirm E-mail Address

Applications - BCBSLA/HMO LA
Application for Individual Health Coverage     01MK5314
BlueChoice 65 Application Booklet     23XX2461

Applications Attachments
BCBSLA Individual Health Change of Status Card     23XX0350
BCBSLA List Bill Agreement to Provide Payroll Deduction Services     23XX7478
BCBSLA List Bill Authorization for Payroll Deduction (carbon)     23XX7480
BCBSLA List Bill Disclosure Statement     23XX7479
BCBSLA Prior Carrier Health Coverage Form     23XX1938
Variable Income Plan Disclosure Notice     23XX2037

Blue 365     01MK4375
Blue Connect     01MK4872
Blue Cross Multi-State Plan Brochure     01MK5331
Blue Dental Certified     01MK5878
Blue Dental Traditional     01MK5877
BlueChoice 65 Brochure     23XX2446
BlueChoice 65 Outline of Medicare Supplement Coverage     23XX2475
BlueSaver PPO Insert     01 MK 1453
Cancer and Serious Disease Brochure     23XX1628
Community Blue     01100 01236
Dental Flyer     01MK4458
Guide to Health Insurance for People with Medicare     23XX1849
Individual Solutions Brochure     01MK4558
VIP(Variable Income Plan) Brochure     23XX4119

Other Commonly Used Forms
Affidavit Acknowledging Insurance Acceptance     23XX1861
Attn: Individual Marketing Support Envelopes     01EN1593
BCBSLA/HMO LA Authorization to Draw Check on My Account     06AC0019
Diabetic Questionnaire     23XX1936
Envelope (Yellow Mem Bill)     01EN1594
Health Insurance Claim Form     23XX6537
High Blood Pressure Report     23XX5551
Medical Guide Questionnaire     01MK1763
Physical Examination Report     23XX5543
Prescription Drug Claim Form     23XX4157
Supplemental Medical History     23XX1899
Supply Fax Order Form     23XX0261
VIP Claim Form     23XX0808

Provider Directories - BCBSLA
BlueChoice 65 Select Member Hospitals by Parish     23XX2665
PPO Alexandria     00000
PPO Baton Rouge     00000
PPO Lafayette     00000
PPO Lake Charles     00000
PPO Monroe     00000
PPO New Orleans     00000
PPO Shreveport     00000

Provider Directories - HMO LA
Blue Connect     00000
Community Blue     01100 01203
Community Blue Pharmacy Directory     01100 01204
HMO Baton Rouge     00000
HMO New Orleans     00000
HMO Shreveport     00000