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Employer Forms & Resources

Download and print commonly used forms. All forms are in PDF format. Download Acrobat Reader.

Employer Forms

FORM
DESCRIPTION
Cancel Spouse or Dependent Coverage
This form notifies us to cancel existing coverage for a spouse or dependent.
Electronic Funds Transfer Authorization
Use this form to give BCBSWY authorization to withdraw premium funds from your bank automatically.
Medical Claim Form
Use this form to file a claim for medical services, such as office visits, physical therapy, laboratory services and radiology services such as X-rays.
Transaction Transmittal
Use this form to notify us of a name or address change, or to cancel, transfer or reinstate an employee’s coverage.
 
 

FlexShare Forms

FORM
DESCRIPTION
FlexShare Brochure & Applications
Learn about and apply for FlexShare Benefits.
Plan Amendment Request
Complete this form to amend your employer FSA or HRA Plan.
Premium Only Plan (POP)
Enroll an employee in a Premium Only Plan.
Flexible Spending Account (FSA)
Enroll an employee in a Flexible Spending Account.
Flexible Spending Account (FSA) & Premium Only Plan (POP)
Enroll an employee in a Flexible Spending Account and a Premium Only Plan.
Flexible Spending Account (FSA) with a Health Savings Account (HSA)
Enroll an employee in a Flexible Spending Account with a Health Savings Account.
Health Reimbursement Arrangement (HRA) - Single Rate
Enroll an employee in a Health Reimbursement Arrangement with one level of contribution.
Health Reimbursement Arrangement (HRA) - Multiple Rates
Enroll an employee in a Health Reimbursement Arrangement with two levels of contributions.
Health Reimbursement Arrangement (HRA) & Premium Only Plan (POP)
Enroll an employee in a Health Reimbursement Arrangement and a Premium Only Plan.
Electronic Funds Transfer (EFT)
Authorize BCBSWY to automatically make bank transfers for FlexShare Benefit funds.
 
 

FlexShare Resources

FORM
DESCRIPTION
Who can participate?
Find eligibility for participation in a POP, FSA or HRA.
Change in Status Matrix for FSA
Explains qualifying events that allow participants to change an election for FSA healthcare or dependent care.
Expenses that Qualify for FSA Reimbursement
Common expenses that qualify for reimbursement.
 
 

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