Forms for Members
Use the links below to print/view copies of our most frequently used forms.
Prescription Claim Forms
- Prescription Drug Claim FormOpen a PDF - Use for prescriptions that were purchased on or after Jan. 1, 2017.
- Dental Claim FormOpen a PDF
- International Claim FormOpen a PDF - 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 Open a PDF
- International Claim Form in European A4 Paper SizeOpen a PDF
- Medical Claim FormOpen a PDF - 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 FormOpen a PDF - **For members with Vision Care II policies only. All others, use medical claim form above.
- Surprise Bill Assignment of Benefits FormOpen a PDF - 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 FormsOpen a PDF - This link will take you to the Lifetime Benefit Solutions Website.
- Advance Care PlanningOpen a PDF
- Manage Your PrivacyOpen a PDF
Membership & Enrollment Forms
- Away From Home Care Guest Membership ApplicationOpen a PDF
- Blue Choice, BluePoint2, BluePoint3, DentalOpen a PDF
- Continuing Coverage for Students on Medical Leave FormOpen a PDF
- Dental Coverage Attestation Form Open a PDF
- Dependent Certification FormOpen a PDF
- Disabled Dependent FormOpen a PDF
- HealthyBlueOpen a PDF
- Healthy New York Recertification Open a PDF
- Member Change Form for Direct Purchase PlansOpen a PDF
- Prior Coverage Verification FormOpen a PDF
- SimplyBlueOpen a PDF
- Young Adult Option Certification FormOpen a PDF
- SimplyBlue Gym Membership Incentive Reimbursement FormOpen a PDF