Forms
- ID card order form (BlueAccess log-in required)
- Authorization for Release of Protected Health Information (HIPAA form) *
(Form 29-456)- Autorización para divulgar la Información médica protegida *
(Formulario 29-456es)
- Autorización para divulgar la Información médica protegida *
- State of Kansas Employee Claim Form *
(Form 34-4)- Formulario-de-reclamo *
(Formulario 34-4es)
- Formulario-de-reclamo *
- Blue Cross Blue Shield Global Core Claim Form (offsite link)
- Claim Appeal Form *
(Form 34-730WEB)- Sus derechos de apelación de reclamaciones y formulario de apelación *
(Formulario 34-730WEBes)
- Sus derechos de apelación de reclamaciones y formulario de apelación *
- Claim Appeal Representative Authorization Form *
(Form 29-58)
* These fillable 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.
You will be reimbursed for covered services.
What should I do with my claims if I go to a provider in another state?
If you receive services in another state, you will need to know if the provider is participating with the Blue Cross and Blue Shield Plan in that state. If so, the provider will need to submit the claims directly to that state's Blue Cross and Blue Shield Plan. If not, you may submit the claims to us for processing. Be sure to indicate on the claim that the provider does not participate with their state's Blue Cross and Blue Shield Plan.