Below are some of the most commonly used forms. Our forms are updated regularly. Please use the most current form to avoid delays in processing. Read each form carefully for special instructions and/or submission information.
Use this form to claim reimbursement for influenza vaccinations (flu shots) if the flu shot provider does not file a claim for you. Important instructions on how to complete the form are outlined in steps 1-5 at the top of the form.
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.
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.
Usted debe utilizar esta forma si necesita autorizar a otra persona, empresa o grupo de personas/empresas para que ellos reciban o tengan acceso a su información de salud confidencial. Esta forma solo debe llenarse cuando decida cambiar o agregar personas para que tengan acceso a esta información.
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.
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.
Through the BlueCard Worldwide Program, you have access to medical assistance services, doctors and hospitals around the world. Verify your international benefits with Blue Cross customer service at 1-800-392-4089 before leaving the United States; benefits may be different outside the country.
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