Excellus Bluecross BlueShield logo
Login | Register | Forgot Username | Forgot Password
Program Offerings
By Phone
By Email
By Mail
Visit Us In-Person
Frequently Asked Questions
News & Updates
Print Forms
Compliance Notices
Forms for Members
Forms for Members

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

  • Claim Forms
  • Compound Prescription Drug Claim Form - The Compound Prescription Drug Claim Form must also accompany the Prescription Drug Claim Form (enclosed) 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 - 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.
  • 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.
  • 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
  • Disabled Dependent Form
  • HealthyBlue
  • Member Change Form for Direct Purchase Plans
  • Prior Coverage Verification Form
  • SimplyBlue
  • Special Enrollment Attestation
  • Young Adult Option Certification Form
  • Reimbursement Forms
  • SimplyBlue Gym Membership Incentive Reimbursement Form

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

Home     News & Updates    Print Forms    About Us    Fraud & Abuse    Glossary    Accreditations   
Copyright © 2016, Excellus BlueCross BlueShield, a nonprofit independent licensee of the Blue Cross Blue Shield Association. All rights reserved. View our Privacy Policy for information on how we protect your privacy. Use of this site indicates your acceptance of our Terms of Use. Follow this link to view our 31 county New York State service area. You will need Internet Explorer or Firefox to use the secure features of this site.