Forms and Materials Individual Forms Request

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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.

	Information: Producer Name: First    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 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 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 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           Please press the Submit button only once to have this form sent.