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Forms

• Address Change Form
  
• ID Card Order Form
• Primary Care Physician (PCP) Change Form

The following forms were created with Adobe Acrobat. Visit the Adobe Web site to download the latest version of Acrobat Reader.

Miscellaneous Forms

• Authorization for Release of Protected Health Information (HIPAA form)
  (Form 29-456)
• Automatic Payment Authorization
  (Form 29-806)
• COBRA Active Participant Form
  (Form 40-27)
• Coverage of Handicapped Dependent Child Application
  (Form 15-411)
• Dependent Child Affidavit
  (Form 29-158)
  
• OPL Questionnaire (please submit to the Blue Cross and Blue Shield plan in your service area, if your coverage isn't through BCBSKS)
• Value Blue Income Verification Form for Renewing Members
  (Form MC546R)

Claim Forms

• Blue Select Claim Form
  (Form 29-303)
• BlueCard Worldwide International Claim Form
  
• Claim Appeal Form
  (Form 34-730)
• Claim Appeal Representative Authorization Form
  (Form 29-58)
• Drug Claim Form
  (Form 34-275)
• Hospital Indemnity Plan Claim Form
  (Form 29-142)
• Member Claim Form (to be used when submitting both medical and drugs)
  (Form 34-4) *
• Plan 150 Claim Form
  (Form 29-134)
• Premier Blue Member Claim Form
  (Form 87-12)
• Prescription Drug Claim Form (Prime Therapeutics)
  (Use this form to submit a claim only if you have BlueRx Direct.)
  (Form 34-148)
• PrimeMail Order Form
• PrimeMail Refill Order Form
  
• Qualified Medical Child Support Claim Form
  (Form 34-438)
• Qualified Medical Child Support Claim Form - BlueRx
  (Form 34-246)
• State of Kansas Employee Claim Form
  (Form 34-441)