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Forms for Members

  • Application for HealthyBlue
  • SimplyBlue
  • Advance Care Planning for health care proxies, living wills and more
  • Privacy Forms
  • 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.
  • Dental Claim Form
  • Flexible Spending Account or Medical Reimbursement Account Forms This link will take you to the EBS-RMSCO Website.
  • Prescription Drug Claim Form
  • Vision Claim Form - **For members with Vision Care II policies only. All others, use medical claim form above.
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