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.

Claim Forms

  • 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.
  • 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.

General Forms

  • 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

Reimbursement Forms

  • SimplyBlue Gym Membership Incentive Reimbursement FormOpen a PDF

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.