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For Members

Forms for Members

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.
  • Claim Forms

  • 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.
  • 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.