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 Lifetime Benefit Solutions 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
  • Healthy New York Recertification
  • 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.

Some forms may not apply to your coverage and benefits. To obtain other forms not listed here, please contact Customer Services.