Forms and Tools

Sheet of paper with list of items Toolbox

Authorized Delegate

This form is used for you to give Blue Cross permission to share your protected health information with another person or company.

Download Authorized Delegate Form

Forma De Autorización Delegada

Other Authorized Delegate Forms
Blue Benefit Services

Federal Employee Program

Office of Group Benefits

Other Coverage Questionnaire

Important note: You need to provide this information once every two calendar years in order for us to process your claims. If we do not have a current form on file for you and any dependents, we cannot process any of your claims.


Download Other Coverage Questionnaire

Injury and Illness Form

Tell us as much as you can about your injury or illness. Leave blank any information that doesn't apply to you. If we have more questions, we will contact you.
Fill Out Injury or Illness Form

Appeal and Claim Forms

APPEAL FORMS

Dental Appeals

Medical Appeal Request

Administrative Appeal Request

CLAIM FORMS

Attending Dentist Statement

Health Insurance-Blue Cross

Health Insurance-HMOLA

Prescription Drug

Other Forms

Affidavit for Deceased Members

Alternative Dental Claim

Authorization of Use/Release of Protected Health Information (PHI)

Automatic Bank Draft

Formulario de Autorizactión para girar cheques contra mi cutenta (Spanish version of Automatic Bank Draft form)

Change of Status

Tarjeta de cambio de estatus individual (Spanish version of Change of Status form)

Continuity of Care Request

Indian Health Service Referral Form

Individual Plan Cancellation Form (Death of Policyholder)

Individual Plan Cancellation Form (Death of Policyholder) (Spanish)

Reinstatement Request

VIP Claim Form

By using this site, you agree to our use of session replay tools to collect real-time information about your use of our site. We only use the information to optimize the performance of our website, fix errors and prevent fraud. Selecting "no" keeps the information collected anonymous.

Yes No