Forms

The following forms will help you manage your BCBSRI plan:
Electronic Enrollment Authorization Form

Electronic Enrollment Authorization Form

Electronic Payment Option Form
Electronic Payment Form to have your group's monthly premium payment electronically deducted from your group's checking account. Please note: The Electronic Payment Option is only available to groups purchasing health and/or dental coverage directly with BCBSRI.  If you purchased coverage through HealthSource RI, please call 1-855-651-7873 for information about payment options. 
Employer Support Inquiry

Please use this form to submit an inquiry to the Employer Support Team.

Group Activity Report (GAR)

Group Activity Report

Group Activity Report (GAR) Instruction Sheet

Group Activity Report (GAR) Instruction Sheet

Group Dependent Addendum

Group Dependent Addendum

Group Enrollment Checklist

Group Enrollment Checklist

Group Plan65 Member Application

Group Plan65 Member Application

Request for Amendment to the Sales Agreement

Request for Amendment to the Sales Agreement

Small Group Member Application

Small Group Member Application

Small Group Sales Agreement

Small Group Sales Agreement

Your Blue Shop Eligible Population Census Form

Your Blue Shop Eligible Population Census Form

Your Blue Shop Web Enrollment Authorization Change Form
This form should be used by the Group’s authorized representative, or the Primary Administrator of the Agency/Broker firm to make changes to who is permitted access to the Blue Cross & Blue Shield of Rhode Island (BCBSRI) web enrollment tool.
Your Blue Shop Web Enrollment Authorization Form
This form authorizes your employees and/or your Agency/Broker to use the Blue Cross & Blue Shield of Rhode Island (BCBSRI) web enrollment tool specified above as Administrators conducting enrollment on your Group's behalf.