Member Forms

Forms

• Address change form (BlueAccess log-in required)
• ID card order form (BlueAccess log-in required)
• Duplicate coverage questions (BlueAccess log-in required)
• Release of Protected Health Information (user authentication 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.

Miscellaneous forms

• Affidavit of Member's Heirs *
  (Form 34-171)
• Authorization for Release of Protected Health Information (HIPAA form) *
  (Form 29-456)
  • Spanish Version *
• Authorization for the Release of Protected Health Information (PHI) relating to Substance Use Disorder *
  (form 29-456A)
  • Spanish Version *
• Revocation of Authorization for the Release of Protected Health Information (HIPAA form) *
  (Form 29-457)
  • Spanish Version *
• Automatic Payment Authorization *
  (Form 29-806)
• Change Form for BlueCare Non-Group Coverage *
  This form is not intended for use by Marketplace enrollees.
  (Form BC420)
• Change Form for First Choice Coverage *
  (Form 29-462)
• Application for Coverage of Dependent With Disabilities *
  (Form 15-411)
• Dependent Child Affidavit *
  (Form 29-158)
• Duplicate Coverage Questions *
  (Form 34-705)
• Home Delivery Order Form (Mail Order Form) (offsite link)
• Value Blue Income Verification Form for Renewing Members *
  (Form MC546R)
• Alteration/Forgery/Unauthorized Signature Affidavit *

Claim forms

• Blue Cross Blue Shield Global Core Claim Form (offsite link)
• Cancer Plan Claim Form *
  (Form 29-134)
• Claim Appeal Form *
  (Form 34-730WEB)
  • Spanish version *
• How to read your Explanation of Benefits (EOB)
  • Cómo leer su Explicación de Beneficios (Spanish version)
• Claim Appeal Representative Authorization Form *
  (Form 29-58)
• Hospital Indemnity Plan Claim Form *
  (Form 29-142)
• Member Claim Form *(to include prescription drugs processed by BCBSKS)
  Use this form to submit a claim for a prescription drug charge for any BlueRx product, excluding BlueRx Direct.
  (Form 34-4)
  • Spanish version *
• Prime Therapeutics Prescription Drug Claim Form *
  Use this form to submit a claim for a prescription drug charge if you have BlueRx Direct.
  (Form 34-148)

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