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Forms
All forms require the free Adobe Acrobat for viewing and printing.
 SECURE DENTALONE APPLICATION - Print off this application or go under "Related Links" to apply online.
SECURE DENTALONE BROCHURE - Secure DentalOne offer 3 plans! Available to individuals or small businesses! Apply online (go under RELATED LINKS) or print off the paper application.
Aetna Brochure - Learn about every plan Aetna offers in Georgia.
Application - Complete and fax to 770-904-6668 for processing.
Lab Result Request - AIG uses Clinical Reference Lab for processing your lab work. Fax this form to receive your report quickly.
Agent of Record - Let us help you through claims or policy questions, rate increases and making changes to your policy at NO COST TO YOU! Print off and fax this form for immediate service! (Must have had your BCBS policy for 12 months.)
Application & Change Form - Health - Paper App (not for employer/employee use) for faxing or mailing. Call our office for processing instructions.
Bank Draft - Set up bank draft or change your current draft. (One is included with the application.)
Brochure - HSA Forward Focus - High deductible plans that your CPA has recommended for tax savings!
Brochure - SmartSense Plus & Premier Plus (POS) - Plans using the Point of Service (POS) network of providers.
Brochure - SmartSense Plus & Premier Plus (PPO) - Plan using the Preferred Provider (PPO) network.
Brochure - Tonik PPO Plan - Newest plan for young adults who live life to it's fullest. Includes dental and vision benefits! (Not available to under 18 years of age.)
Dental Application for Individuals & Families - Use only if adding dental to your current heath plan OR if applying for dental without a current health plan.
Dental Brochure of Individuals & Families - Monthly Rates:
Individual $27
Family $76
PROVIDER DIRECTORY (Online) for all plans
SmartSense Drug Formulary - Check this formulary BEFORE adding the ENHANCED DRUG RIDER. You might not need it!
Application or Change Form - Download and fax to our office direct. Fax 770-904-6668.
Benefits Booklet - Brief outline of all plans available in Georgia for individuals.
Brochure - 3080 and 4080 Plans - Both $30 or $40 copays with 80/20 coinsurance.
Brochure - 4070 Plan - $40 Copay 70/30 Plan
Brochure - 4070 Value - $40 Copay 70/30 Value Plan
Brochure - HSA 100 Plans
Brochure - HSA 80
Brochure - PPO Plans
Continuation of Coverage Statement - Verification that Consumers Life will cover pre-existing conditions under certain circumstances!
Application - Simply print, complete and fax to 770-904-6668. Call us if any questions at 770-967-1111.
Bank Draft or Billing Change Form - Use for changing banking info or switching to monthly billing.
Bank Draft Verification - CORPORATE - Used when the bank draft is on a CORPORATE account. Submit regular bank draft form as well.
Bank Draft Verification - SOLE PROPRIETOR - Required if premiums are being paid from a SOLE PROP business account. Use along with the bank draft form.
Brochure - $30 Copay Plan
Brochure - $35 Copay Plan
Brochure - $45 Copay Plan
Brochure - Fusion Plan - High deductible, 100% coinsurance and copays!
Brochure - High Ded Plan - H.S.A. Compatible. Tax benefits!
Change Form - For policy changes in benefits, adding or removing dependents or name and address info. NOT FOR BILLING CHANGES.
CoventryOne Dental Application
CoventryOne Dental Benefits
Rx Preauthorization Form - To be completed by your physican for all Rx requiring preauth.
Application - Telephone Checklist - For TELEPHONE APPLICATIONS. Be prepared for the fastest way to process your application.
Application (Paper) - Complete and fax to 770-904-6668. (Or you can do the telephone interview app process instead. See Application - Telephone Checklist)
Brochure - Health Plans - See all their plans in GA!
Dental - HMO Prepaid Plan (C550) Application
Dental - HMO Prepaid Plan (C550) Brochure - Most cost effective plan with comprehensive dental benefits.
Dental - PPO Preventative Plus Application
Dental - PPO Preventative Plus Brochure - Most flexibility. Comprehensive dental plan.
Application - Complete and fax to our office at 770-904-6668. We'll take it from there!
Brochure - GA's only HMO plan available to individuals. (Choose with or without Rx benefits!)
2012 Medicare & You
APPLICATION - Online for BCBS of GA Medicare Approved Plans - Choose between the traditional med supp., the new personal advantage plans and the Rx plans.
Appointment Request Form - Required by Medicare to be signed by any individual seeking a face-to-face appointment. If concerned, refer to the last 2 pages from Medicare's TRAINING for AGENTS for validation.
BCBS Medicare Advantage HMO w/Rx (Application)
BCBS Medicare Advantage HMO w/Rx (Brochure) - Only Counties: Bryan, Chatham, Cherokee, Clayton, Cobb, Coweta, DeKalb, Effington, Forsyth, Fulton, Gwinnett, Harris, Henry, Muscogee, Rockdale and Talbot
BCBS Medicare Advantage HMO w/Rx (Provider Directory) - Refer to the online directory for up to date information. Also you may contact the provider directly to confirm.
BCBS Medicare Advantage PPO w/Rx (Application)
BCBS Medicare Advantage PPO w/Rx (Brochure) - Counties: Appling, Bibb, Bryan, Butts, Chatham, Cherokee, Cobb, DeKalb, Douglass, Forsyth, Fulton, Gwinnett, Harris, Henry, Jeff David, Jones, Liberty, Long, Meriwether, Montgomery, Muscogee, Newton, Paulding, Peach, Rockdale, Spalding, Talbot, Toombs, Twiggs and Wayne.
BCBS Medicare Advantage PPO w/Rx (Provider Directory) - Refer to the online directory for up to date information. Also you may contact the provider directly to confirm.
BCBS Rx Only Plan (Application) - Available to all counties in GA.
BCBS Rx Only Plan (Brochure) - All Counties in GA: Part D can be used with or without a traditional supplement, but not with any of BCBS HMO or PPO (Medicare Advantage) plans.
BCBS Rx Plan Plus (Formulary)
BCBS Rx Plan Premier (Formulary)
BCBS Rx Plan Standard (Formulary)
BCBS Traditional Medicare Supplement (Application) - Available to all counties in GA.
BCBS Traditional Medicare Supplement (Brochure) - This plan works directly with Medicare Parts A & B. Does NOT include Rx Benefits.
PROVIDER DIRECTORY (Online) for all plans
Application for Medico - Paper app for new dental, vision and hearing plan for individuals.
Brochure for Medico - Learn about the new dental plan that includes vision and hearing as well. Very economical and easy to use.
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© 2012 Copyright Brackett Insurance Consultants
Email: Info@PolicyHunters.com
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P.O Box 1105 | Buford, GA 30515
Main: 770-967-1111
Toll-free: 1-877-967-4732
Fax: 770-904-6668
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