Information:
Producer Name:

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Middle
   
Last
Producer Number:
Street Address:
(Please include suite number, route number, etc. We cannot deliver to P.O. Boxes.)
City:
State:
Zip:
Phone:
Fax:
E-Mail Address:

Form Name     Number             Quantity


Applications - BCBSLA
BlueChoice 65 Application Booklet 23XX2461
BlueSaver Application Packet 01MK1737
BM/BV Application Packet 01MK1738
Cancer and Serious Disease Application 23XX1628A


Applications - HMO LA
HMO/POS Application Packet 01100 00925


Applications Attachments - BCBSLA
BCBSLA Individual Health Change of Status Card 23XX0350
BCBSLA List Bill Agreement to Provide Payroll Deduction Services 23XX1869
BCBSLA List Bill Authorization for Payroll Deduction (carbon) 23XX1870
BCBSLA List Bill Disclosure Statement 23XX1915
BCBSLA Prior Carrier Health Coverage Form 23XX1938
Variable Income Plan Disclosure Notice 23XX2037


Applications Attachments - HMO LA
HMO LA Individual Change of Status Card 01100 00007
HMO LA List Bill Agreement to Provide Payroll Deduction Services 04100 00360
HMO LA List Bill Authorization for Payroll Deduction (carbon) 04100 00361
HMO LA List Bill Disclosure Statement 04100 00359
HMO LA Prior Carrier Health Coverage Form 01100 00040


Brochures
BlueChoice 65 Outline of Medicare Supplement Coverage 23XX2475
Blue Choice 65 Brochure 23XX2446
Blue Max Brochure 23XX4116B
BlueSaver Brochure 23XX3127
BlueSaver PPO Insert 01 MK 1453
BlueSaver Tax Deductible List 01MK1552
BlueSelect Brochure 01MK2067
Blue Value Brochure 23XX959
Cancer and Serious Disease Brochure 23XX1628
Guide to Health Insurance for People with Medicare 23XX1849
HMO Point of Service Brochure 01100 00752
Individual Product Comparison Chart 01MK1712
Look Listen...and Save! (BC65) 23XX2349
Look Listen Smile 23XX2293
VIP(Variable Income Plan) Brochure 23XX4119


Other Commonly Used Forms
Affidavit Acknowledging Insurance Acceptance 23XX1861
Appointment of Representative to Submit an Electronic Document and Signature of Insurance Coverage 01MK1745
Attn: Individual Marketing Support Envelopes 01EN1593
BCBSLA Authorization to Draw Check on My Account 23XX1346
BCBSLA/HMO LA Rate Disk 01MK2053
Dependent Certification(student since age 21) 24XX0205
Dependent Certification(student since age 19) 24XX0205.1
Diabetic Questionnaire 23XX1936
Envelope (Yellow Mem Bill) 01EN1594
Health Insurance Claim Form 23XX6537
High Blood Pressure Report 23XX5551
HMO LA Authorization to Draw Check on My Account 01100 00855
Medical Guide Questionnaire 01MK1726
Physical Examination Report 23XX5543
Prescription Drug Claim Form 23XX4157
Retention Grid 01MK1460
Supplemental Medical History 23XX1899
Supply Fax Order Form 23XX0261
Unacceptable Medical Risk 23XX6435
VIP Claim Form 23XX0808


Provider Directories - BCBSLA
BlueChoice 65 Select Member Hospitals by Parish 23XX2665
Dental Provider Listing 23XX6689
KEY Alexandria  
KEY Baton Rouge  
KEY Lafayette  
KEY Lake Charles  
KEY Monroe  
KEY New Orleans  
KEY Shreveport  
PPO Alexandria  
PPO Baton Rouge  
PPO Lafayette  
PPO Lake Charles  
PPO Monroe  
PPO New Orleans  
PPO Shreveport  
Vision & Hearing Provider Listing 23XX6691


Provider Directories - HMO LA
HMO Baton Rouge  
HMO New Orleans  
HMO Shreveport  
 
     
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