- 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.
- Affidavit of Member's Heirs *
- Authorization for Release of Protected Health Information (HIPAA form) *
- Authorization for the Release of Protected Health Information (PHI) relating to Substance Use Disorder *
- Revocation of Authorization for the Release of Protected Health Information (HIPAA form) *
- Automatic Payment Authorization *
- Change Form for BlueCare Non-Group Coverage *
This form is not intended for use by Marketplace enrollees.
- Change Form for First Choice Coverage *
- Application for Coverage of Dependent With Disabilities *
- Dependent Child Affidavit *
- Duplicate Coverage Questions *
- Home Delivery Order Form (Mail Order Form) (offsite link)
- Value Blue Income Verification Form for Renewing Members *
- Alteration/Forgery/Unauthorized Signature Affidavit *
- Blue Cross Blue Shield Global Core Claim Form (offsite link)
- Cancer Plan Claim Form *
- Claim Appeal Form *
- How to read your Explanation of Benefits (EOB)
- Claim Appeal Representative Authorization Form *
- Hospital Indemnity Plan Claim Form *
- 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.
- Prime Therapeutics Prescription Drug Claim Form *
Use this form to submit a claim for a prescription drug charge if you have BlueRx Direct.
* You may fill out and print this form using your PDF reader program.