Order Form For Group Administration Supplies

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Blue Cross and Blue Shield of Kansas Claim Forms
Quantity Form Number Description
34-400 National & special insured claim form (yellow)
34-4 Insured claim form (blue & white)
34-275 Prescription drug claim form (white)
34-152 BlueRx direct drug claim form (white)


Blue Cross and Blue Shield of Kansas Applications/Change Forms
5-105 Hospital indemnity plan application
5-14 Plan 150 application
40-106 Waiver card
29-151 Change form
29-298 COBRA declaration
40-127 Coverage application / group application


Order Forms and Supplies
5-22 Order form for group administration supplies
N/A Schedule of benefits