Members   Providers   Employers   Forms   Prescription Drugs   What to do When

Forms

• 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 Web site 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)
• Automatic Payment Authorization
  (Form 29-806)
• Change Form for First Choice Coverage *
  (Form 29-462)
• COBRA Active Participant Form
  (Form 40-27)
  • Attestation Form (Use when seeking treatment as an assistance eligible individual as related to the American Recovery and Reinvestment Act of 2009)
    (Form 40-24)
• Coverage of Handicapped Dependent Child Application
  (Form 15-411)
• Dependent Child Affidavit
  (Form 29-158)
  
• Duplicate Coverage Questions
  (Form 34-705)
• Value Blue Income Verification Form for Renewing Members
  (Form MC546R)

Claim Forms

• BlueCard Worldwide International Claim Form
  
• Claim Appeal Form
  (Form 34-730)
  • Spanish version
• Claim Appeal Representative Authorization Form
  (Form 29-58)
• Hospital Indemnity Plan Claim Form
  (Form 29-142)
• Member Claim Form
  (Form 34-4) *
• Plan 150 Claim Form
  (Form 29-134)
• Prescription Drug Claim Form (Prime Therapeutics)
  (Use this form to submit a claim only if you have prescription drug coverage through your employer. Otherwise, use the Member Claim Form (Form 34-4) above.)
  (Form 34-148)
• PrimeMail Order Form
• PrimeMail Refill Order Form
  

SelectAccount Forms

• See the Spending Accounts section for a list of available forms