2018 Option Transfer Forms

(for current members changing plans)

Form for Your Region Counties in this Region
CNY PPO Option Transfer Form Broome - Cayuga - Chemung - Chenango - Cortland - Jefferson - Lewis - Onondaga - Oswego - St. Lawrence - Schuyler - Steuben - Tioga - Tompkins
East PPO Option Transfer Form Clinton - Delaware - Essex - Franklin - Fulton - Hamilton - Montgomery - Otsego
Rochester HMO Option Transfer Form Livingston - Monroe - Ontario - Seneca - Wayne - Yates
Utica-Rome PPO Option Transfer Form Herkimer - Madison - Oneida

2018 Medicare Plan Applications

(for new enrollments)

Plan Application for Region in these Counties
Medicare BlueBasic PPO, Medicare BlueClassic PPO, Medicare BlueSecure PPO, Medicare BlueEnhanced PPO, Medicare BlueEssential PPO CNY Broome - Cayuga - Chemung - Chenango - Cortland - Jefferson - Lewis - Onondaga - Oswego - St. Lawrence - Schuyler - Steuben - Tioga - Tompkins
Medicare BlueBasic PPO, Medicare BluePlus PPO East Clinton - Delaware - Essex - Franklin - Fulton - Hamilton - Montgomery - Otsego
Medicare Bassett HMO East Delaware - Otsego
Medicare Blue Choice Value HMO, Medicare Blue Choice Value Plus HMO, Medicare Blue Choice Optimum HMO-POS, Medicare Blue Choice Platinum HMO-POS, Medicare Blue Choice Select HMO-POS Rochester Livingston - Monroe - Ontario - Seneca - Wayne - Yates
Medicare BlueBasic PPO, Medicare BlueClassic PPO, Medicare BlueSecure PPO, Medicare BlueEnhanced PPO, Medicare BlueEssential PPO Utica-Rome Madison - Oneida
Medicare BlueBasic PPO, Medicare BlueClassic PPO, Medicare BlueSecure PPO, Medicare BlueEnhanced PPO, Medicare BlueEssential PPO, Medicare Bassett HMO Utica-Rome Herkimer

Prescription Claim Forms

Claim Forms

Other Forms

Privacy Forms

Federal privacy laws prohibit us from disclosing your protected health information to another person or organization without your written authorization (with some exceptions, like your physician). Our Privacy Policy describes other exceptions that may apply.

We're committed to protecting your privacy

If you or a family member (age 18 or older) covered under your contract wish to designate another individual to receive information related to your health insurance and protected health information, please complete a disclosure authorization online or by using the forms below. An authorization form must be completed and returned to us for each person you or your family member wish to authorize.

Enter/Update Authorizations (requires login), or

Use these forms to Submit Authorizations by Mail:

Accessing Your Protected Health Information

Request a copy of your PHI to view or to request a change.

Disclosure Accounting

Request a list of instances your PHI was disclosed (with some exceptions).

Confidential Communications

Request that we communicate with you at an alternate address (if you are endangered).

Excellus BlueCross BlueShield contracts with the Federal Government and is an HMO plan and PPO plan with a Medicare contract. Enrollment in Excellus BlueCross BlueShield depends on contract renewal. Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. .
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