MEMBER FORMS

Occasionally a member may need to make a change to their benefits, appeal a claim denial, submit a claim, etc. Members will find the necessary forms to complete those actions and others below. If you have questions about a particular form or you are not sure which form you need, contact OGB Customer Service at 1-800-272-8451.

GB-01 Enrollment/Change Form

New employees complete this form and return to their HR department within 30 days of their hire date. This form can also be used for an enrollee experiencing a qualifying event and needs to make a change to his/her coverage.

GB-03 Address or Name Change Form

Members must use this form for name changes or address changes and send it to the Office of Group Benefits – Eligibility section. Members can also make changes to their name or address on LEO (LaGov paid employees only).

GB-04 Automatic Bill Payment Authorization Form

This form is completed by the member to automatically debit their checking account to pay premiums along with required attached documents.

GB-06 Request for Continuation of Coverage for Incapacitated Dependent Child

This form is required when a member is submitting information for continued coverage on a handicap child.

GB-20 2017 Medicare Part D High-Income Surcharge Verification

The member completes this form to receive reimbursements quarterly when CMS advises. The member is responsible for monthly surcharges on Part D drugs due to high income.

GB-20 2018 Medicare Part D High-Income Surcharge Verification

The member completes this form to receive reimbursements quarterly when CMS advises. The member is responsible for monthly surcharges on Part D drugs due to high income.

GB-21 Retiree 100 Application

This program serves as additional coverage for retired members who have extensive hospital bills and/or large amounts of physician charges. Retiree 100 is available to members that are enrolled in a Magnolia Open Access Plan/ and Medicare is the primary insurer. The member completes this form for enrollment. You can enroll within 30 days before or after the date you become eligible for Medicare (Part A and B) during annual enrollment or 30 days before or after retirement.

GB-53 Almost 65

This form is sent to members 30/90 days prior to the plan member/spouse reaching the age of 65 giving important information about changes that may affect their OGB Health coverage.

GB-79 Health Savings Account Enrollment & Payroll Deduction Election/Change Form

Health Savings Account Enrollment & Payroll Deduction Election/Change Form.

Blue Cross Appeal Form

Plan member/spouse/parent/guardian/provider or authorized delegate. This form must be completed within 180 days of the denial and submitted to Blue Cross Blue Shield Appeals and Grievance Coordinator.

Flu Vaccination Claim Form

Plan member completes this form for flu vaccination claims that are not filed by a network provider.

Health Savings Account (HSA) Transfer/Rollover Request Form

Member completes this form to request an HSA transfer or rollover. A rollover is a way to move money or property from a Medical Savings Account (MSA) or existing Health Savings Account (HSA) to a new HSA.

Sample Explanation of Benefits

Sample Explanation of Benefits.

Health Equity Return Mistaken HSA Contribution Form

The member completes this form if they determine they have made ineligible HSA contributions and have NOT used their HSA funds. This form will reverse all ineligible contributions to the member’s employer for proper tax handling. Funds not contributed by OGB will be reimbursed to the member after appropriate taxes have been applied.

Health Equity Mistaken HSA Distribution Form

The member completes this form if they determine they have made ineligible HSA contributions and HAVE used some or all of their HSA funds. The member must reimburse his account according to the directions on the form. This form will reverse all ineligible contributions to the member’s employer for proper tax handling. Funds not contributed by OGB will be reimbursed to the member after appropriate taxes have been applied.

Blue Cross Medical Records Request Form

A member may request a copy of their, and/or their eligible dependent(s), medical and/or insurance records by filling out this form and submitting it to the BCBS Legal Department. The member should be sure to include their full first and last name, policy number, date of birth, social security number and a brief description of what they are after, such as a detailed claims listing, medical records, tax documents, certificates of coverage, policy booklets, etc.

Legal Custody Dependent Attestation Form

The following requirements and associated documentation must be submitted to OGB in order to have your legal custody dependent covered under your OGB health plan:

  • Legal custody must be granted by the court before the dependent(s) turns 18 years of age
  • Unmarried dependent(s) may remain uncovered until age 21 (24 if they are a full-time student)
  • Provide the following dependent Verification documents to OGB within 30 days of eligibility:
    • Copy of legal custody decree
    • Copy of dependent’s birth certificate
    • Signed attestation form
    • Student verification (if applicable – dependent(s) between the ages of 21-24

Grandchild(ren) Attestation Form

  • Legal custody must be granted by the court before grandchild turns 18 years of age
  • Grandchild must reside with the Plan member
  • Unmarried grandchild may remain covered until age 21(24 if they are a full-time student)
  • Provide the following dependent Verification documents to OGB within 30 days of eligibility:
    • A copy of legal custody decree
    • A copy of grandchild(ren)’s birth certificate
    • Signed attestation form
    • Student verification (if applicable – grandchild(ren) between the ages of 21-24