Customer Forms

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.

Appeals Request 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.

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Authorized Delegate Form

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.

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BlueCard International Claim Form

Through the Blue Cross Blue Shield Global Core 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.

Blue Cross Blue Shield Global Core claims are sent to:
  • Blue Cross Blue Shield Global Core Service Center
    P.O. Box 2048
    Southeastern, PA 19399
  • Click here for International Claim Form
Blue Cross Blue Shield Global Core Service Center
  • 1-800-810-2583 (select international option)
  • 1-804-673-1177 (call collect from outside of the U.S.)

Catapult Expectant Mother Form

If you did not qualify for the wellness incentive or are unable to participate in the onsite preventive checkups because you were pregnant at the time of the checkups, as an alternative you may work with your physician to develop a plan to maintain or improve your health. Complete the form below, have it signed by your personal physician and fax it to Catapult Health at 877-885-9904 by 5:00 PM Central Time on August 31, 2017.

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Catapult Health Primary Care Provider Form

If you were not able to receive a Catapult Health Preventive Checkup this year, you may have your Primary Care Provider report lab and biometric values to receive credit toward the Office of Group Benefits wellness incentive being offered. All information requested below must be completed in order for credit to be awarded. Once complete, you must return your completed forms to Catapult Health by 5:00 pm on August 31, 2017. Please follow the instructions at the bottom of this page. This is your responsibility, not your provider’s. If you are pregnant, please refer to the Expectant Mother Form.

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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.

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Forma De Autorización Delegada

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.

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Health Insurance Claim Form

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.

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OGB Flu Vaccination Claim Form

Use this form to claim reimbursement for influenza vaccinations (flu shots) if the flu shot provider does not file a claim for you.

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Other Coverage Questionnaire

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 Blue Cross 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 Blue Cross, you just need to complete the top portion of the first page of the form, check the "no" box and sign where indicated.

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Request for Continuation of Health Coverage for Incapacitated Child

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