Forms for Members

Our forms are updated regularly, so please use the most current version to avoid processing delays. Please read each form carefully for special instructions and/or submission information.

If you would like to submit an inquiry to Customer Service, please use our secure web-based Customer Inquiry Form.

Alternative Dental Claim Form [18NW1061 R0406]

Use this form to file a dental claim for alternative, non-covered treatment under your Blue Cross policy. Note: If you received services from a participating provider, your claims will automatically be filed for you and you do not need to submit a claim.

Appeals Request Form [23XX7578 0806]

We consider any request to change our coverage decision such as a denied claim, as an appeal. You are encouraged to provide us with all available information and use this appeal request form to help us completely evaluate your appeal.

Authorized Delegate Form [23XX7434 R0508]

This form is to use if you wish to authorize another individual, organization or class of individuals/organizations to receive and access your protected health information that we create and use. This form will only need to be filed once unless you decide to change who is authorized to access your information.

Forma De Autorización Delegada 23XX7434 R0508

Mas información:
Usted debe utilizar esta planilla si usted necesita autorizar otra persona, empresa o grupo de personas/empresas para que ellos reciban o tengan acceso a tu información de salud confidencial. Usted solo debe llenar esta planilla cuando usted decide cambiar o agregar persona(s) que tienen acceso a esta información.

Automatic Bank Draft Form [06AC0019 1013]

You may use this form to authorize Blue Cross and Blue Shield of Louisiana and its affiliate, HMO Louisiana, Inc. to charge to your account a one-time payment or monthly recurring payments at the Bank (or other financial institution) you name. With this form you also authorize the Bank to debit the amount of those charges to your account.

Formulario de Autorizactión para girar cheques contra mi cutenta [06AC0019 1013]

Mas información:
Usted puede utilizar este formulario para autorizar a Blue Cross and Blue Shield of Louisiana y su afiliada, HMO Louisiana, Inc. a cargar a su cuenta un pago único o pagos mensuales recurrentes en el Banco (u otra institución financiera) que usted nombre. Mediante este formulario usted también autoriza al Banco a debitar el monto de dichos cargos a su cuenta.

Continuity of Care Request Form

If your doctor leaves our networks while you are receiving care for certain conditions, you may be eligible to continue care with your doctor at the higher network level of benefits for a limited time. This form must be completed by you and your doctor, and returned to us within 30 days of the doctor leaving our networks.

Dental Claim Form [23XX0609 R0304]

Use this form to file a dental claim under your Blue Cross policy. Note: If you received services from a participating provider, your claims will automatically be filed for you and you do not need to submit a claim.

Health Insurance Claim Form - Blue Cross [23XX6537 R0304]

Use this form to file a claim for benefits under your Blue Cross policy. Note: If you received services from a participating provider, your claims will automatically be filed for you and you do not need to submit a claim. Instructions on how to complete the form can be found on page 2 of the file.

Health Insurance Claim Form - HMO Louisiana [04100 00036 0304R]

Use this form to file a claim for benefits under your HMO Louisiana policy. Note: If you received services from a participating provider, your claims will automatically be filed for you and you do not need to submit a claim. Instructions on how to complete the form can be found on page 2 of the file.

Other Coverage Questionnaire - HMO Louisiana [BA57 R11/11]

This form lets us know if you or any of your dependents are covered by another health insurance plan or Medicare in addition to your HMO Louisiana coverage. Important note: You need to provide this information once every calendar year in order for claims to be processed on your behalf. If we do not have a current form on file on you or your dependents, we cannot process any of your claims.

If you do not have any coverage other than HMO Louisiana, you just need to complete the top portion of the first page of the form, check the "no" box and sign where indicated.

Prescription Drug Claim Form [BSLSTLC.MIG 1/20/06]

Use this form to file a claim for prescription drug benefits under your Blue Cross or HMO Louisiana policy. Instructions on how to complete the form can be found on page 2 of the file.

Producer of Record Change Letter [01MK1940 R0108]

Variable Income Plan (VIP) Claim Form [23XX0808 R01/04]