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Forms for Members

Image Link: Get Adobe ReaderUse the links below to print/view copies of our most frequently used forms. All forms are in a PDF format. If you don't already have Acrobat® Reader, you can download it free at Adobe.com


  • Claim Forms
  • $300 BlueHealthy Dollars Reimbursement Form
  • Claim Form
  • Compound Prescription Drug Claim Form - This form must accompany the Prescription Drug Claim Form for all compound medications
  • Dental Claim Form
  • For Flexible Spending Account (FSA) or Medical Reimbursement Account forms, please visit the EBS-RMSCO website
  • International Claim Form
  • Prescription Drug Claim Form (for services in 2011) - use when another insurance carrier has paid a portion of your claim or when you paid cash for your prescription
  • International Claim Form in Spanish
  • International Claim Form in European A4 Paper Size
  • Prescription Drug Claim Form
  • SimplyBlue Gym Membership Incentive Reimbursement Form
  • Vision Claim Form
  • General Forms
  • Advance Care Planning
  • Manage Your Privacy
  • Membership & Enrollment Forms
  • Blue Choice, BluePoint2, BluePoint3, Dental
  • Away From Home Care Guest Membership Application
  • Child Health Plus Recertification Form
  • Child Health Plus Recertification Form in Spanish
  • Continuing Coverage for Students on Medical Leave Form
  • Dependent Certification Form
  • Handicapped Dependent Application
  • Healthy New York Group Enrollment Form
  • HealthyBlue
  • Non-Group (Direct Purchase) Membership Application
  • SimplyBlue
  • Young Adult Option Certification Form
  • Prior Coverage Verification Form

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

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