- Address Change Form (BlueAccess log-in required)
- ID Card Order Form (BlueAccess log-in required)
- Duplicate Coverage Questions (BlueAccess log-in required)
The following forms were created with Adobe Acrobat. Visit the Adobe website to download the latest version of Acrobat Reader. Version 9.0 or higher is required.
- Affidavit of Member's Heirs
- Authorization for Release
of Protected Health Information (HIPAA form) *
- Automatic Payment
- Change Form for BlueCare Non-Group Coverage *
This form is not intended for use by Marketplace enrollees.
- Change Form for First Choice Coverage *
- Coverage of Handicapped
Dependent Child Application
- Dependent Child Affidavit
- Duplicate Coverage Questions
- Value Blue Income Verification Form for Renewing Members
- Alteration/Forgery/Unauthorized Signature Affidavit*
- PrimeMail Order Form (offsite link)
- PrimeMail Refill Order Form (offsite link)
- Blue Cross Blue Shield Global Core Claim Form (offsite link)
- Cancer Plan Claim Form
- Claim Appeal Form
- Claim Appeal Representative
- Hospital Indemnity Plan Claim Form
- Member Claim Form *
Use this form to submit a claim for a prescription drug charge for any BlueRx product, excluding BlueRx Direct.
- Prescription Drug
Claim Form (Prime Therapeutics)
Use this form to submit a claim for a prescription drug charge if you have BlueRx Direct.
- See the Spending Accounts section for a list of available forms