Forms for members

Medical forms

• Medical claim form - English (PDF) – Request reimbursement for eligible health care services you've received.
• Medical claim form - Spanish (PDF) – Request reimbursement for eligible health care services you've received.
• BlueCard international claim form - English (PDF) – Request reimbursement for eligible health care services you received outside of the United States.
• BlueCard international claim form - Spanish (PDF) – Request reimbursement for eligible health care services you received outside of the United States.
• Digital application for contraception management reimbursement form (PDF) – Request reimbursement for your annual or monthly subscription.

Other forms

• Dental Plan claim form (PDF) – Request reimbursement from your dental insurance for eligible dental care services you've received. (This is for members with a dental plan that's separate from your medical plan.)
• Vision plan claim forms – Request reimbursement from your vision insurance for eligible eye care services you've received.
  • Vision Plan claim form (commercial) (PDF) – This is for people with an individual and family or employer vision plan that's separate from your medical plan.
  • Vision Claim form (Medicare) (PDF) – This is for members of Medicare plans.
• Looking for a COVID-19 over-the-counter at-home test reimbursement form? See the "prescription drugs and pharmacy" section.

Find prescription drug forms and information, such as claim forms and formularies, on the Prime Therapeutics website. You will be asked a few questions so the site can determine which set of forms to show you.

Important: If your prescription drug coverage is not from Blue Cross (through our pharmacy benefits manager, Prime Therapeutics), please contact your pharmacy benefits administrator for the forms you need.

If you’d like to make a complaint or file an appeal about a claim that was denied, start by calling customer service at the number on the back on your member ID card. They can also help determine which form is for your health plan. Learn more about filing a complaint or appeal.

• Blue Plus fully insured complaint/appeal form (PDF) – Use this fillable form if you are a member of a fully insured Blue Plus health plan.
• Blue Cross fully insured complaint/appeal form (PDF) – Use this fillable form if you are a member of a fully insured Blue Cross health plan.
• Blue Cross self-insured complaint/appeal form (PDF) – Use this fillable form if you are a member of a self-insured group health plan.
• Public programs member grievance/appeal form (PDF) – Use this form if you are a member of a public health program.
• Privacy practices complaint form (PDF) – Use this form if you want to file a complaint about Blue Cross’ privacy practices or compliance with our notice of privacy practices.
• Nondiscrimination grievance form (PDF) – Use this form if you want to file a grievance about Blue Cross’ nondiscrimination practices or compliance with our nondiscrimination practices.

• Automatic monthly payment form (PDF) – Set up automatic monthly premium payments from your checking or savings account. It is sometimes called a "Pay-It-Easy" form.

• Authorization for disclosure of health information form (online) – Use this online form to authorize Blue Cross to give information about you to someone else (examples: an agent or family member). This is the most efficient way to do this. Otherwise, you may download a PDF - English.
• Authorization for disclosure of health information form - Hmong (PDF)
• Authorization for disclosure of health information form - Spanish (PDF)
• Cancellation form – learn about how to cancel your individual & family or Medicare plan and get forms
• Consent for Case Management (PDF) – Case management agreement form and release of medical information.
• Power of Attorney form (PDF) – This is not a Blue Cross form, but you may need it if you are managing a loved one’s health care. Consult a lawyer as needed.
• Tax form 1095 – Learn about IRS tax form 1095, which provides information about your health coverage.

Please note: If you're covered by an employer plan, you may need a different form or a different way to add people to your coverage. Please contact your employer.

• Disabled dependent application form (PDF) – Request that a disabled dependent (over 25 years of age) be covered under your plan.