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.
- 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 Lifetime Benefit Solutions Website.
- Advance Care Planning
- Manage Your Privacy
Membership & Enrollment Forms
- Away From Home Care Guest Membership Application
- Blue Choice, BluePoint2, BluePoint3, Dental
- Continuing Coverage for Students on Medical Leave Form
- Dental Coverage Attestation Form
- Dependent Certification Form
- Disabled Dependent Form
- Healthy New York Recertification
- Member Change Form for Direct Purchase Plans
- Prior Coverage Verification Form
- Special Enrollment Attestation
- Young Adult Option Certification Form
- SimplyBlue Gym Membership Incentive Reimbursement Form