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Forms for Members

Use the links below to print/view copies of our most frequently used forms.

  • Claim Forms
  • Compound Prescription Drug Claim Form - This form must accompany the Prescription Drug Claim Form for all compound medications
  • Dental Claim Form
  • International Claim Form - To be used when submitting expenses incurred from rendering medical services overseas.
  • International Claim Form in Spanish
  • International Claim Form in European A4 Paper Size
  • Medical Claim Form - To be used when submitting expenses incurred from rendering medical services from a provider, hospital, DME vendor, etc. This form should not be used to submit Prescription Drug services. All Prescription Drug services should be submitted on the Prescription Drug Claim Form.
  • Prescription Drug Claim Form
  • Vision Claim Form
  • 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.
  • General Forms
  • 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
  • Handicapped Dependent Application
  • Healthy New York Group Enrollment Form
  • HealthyBlue
  • Member Change Form for Direct Purchase Plans
  • Prior Coverage Verification Form
  • SimplyBlue
  • Special Enrollment Attestation
  • Young Adult Option Certification Form
  • Reimbursement Forms
  • $300 BlueHealthy Dollars Reimbursement Form
  • SimplyBlue Gym Membership Incentive Reimbursement Form

To obtain other forms not listed here, please contact Customer Services.

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