Use the links below to print/view copies of our most frequently used forms.
Prescription Claim Forms
Prescription Drug Claim Form 2017
- Use for prescriptions that were purchased on or after Jan. 1, 2017.
Compound Prescription Drug Claim Form 2016
- Use for prescriptions that were purchased during the year 2016. The Compound Prescription Drug Claim Form must also accompany the Prescription Drug Claim Form (enclosed) for all compound medications
Prescription Drug Claim Form 2016
- Use for prescriptions that were purchased during the year 2016.
Dental Claim Form
International Claim Form
- Updated claim form is for use starting on Jan. 1, 2017 when submitting expenses incurred from rendering medical services overseas. Claims should not be submitted before the effective date.
International Claim Form in Spanish
International Claim Form in European A4 Paper Size
Medical Claim Form
- Use to submit medical services from a provider, hospital, DME vendor, etc. Also use for vision services including eyewear (see exception below**). Do not use to submit prescription drug services. All prescription drug services should be submitted on the prescription drug claim form.
Vision Claim Form
- **For members with Vision Care II policies only. All others, use medical claim form above.
Surprise Bill Assignment of Benefits Form
- Use this form if you receive a surprise bill for health care services.
Flexible Spending Account or Medical Reimbursement Account
Flexible Spending Account or Medical Reimbursement Account Forms
- This link will take you to the EBS-RMSCO Website.
Advance Care Planning
Manage Your Privacy
Membership & Enrollment Forms
Away From Home Care Guest Membership Application
Blue Choice, BluePoint2, BluePoint3, Dental
Child Health Plus Recertification Form
Child Health Plus Recertification Form in Spanish
Continuing Coverage for Students on Medical Leave Form
Dental Coverage Attestation Form
Dependent Certification Form
Disabled Dependent Form
Member Change Form for Direct Purchase Plans
Prior Coverage Verification Form
Special Enrollment Attestation
Young Adult Option Certification Form
SimplyBlue Gym Membership Incentive Reimbursement Form