Member Forms | Excellus BlueCross BlueShield

Forms & Applications
Privacy Forms

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

Prescription Drug Claim Form 2017-2018 - Use for prescriptions that were purchased on or after Jan. 1, 2017.
Compound Prescription Drug Claim Form - Use for prescriptions that were purchased during the year 2016. This form must accompany the Prescription Drug Claim Form for all compound medications.
Prescription Drug Claim Form 2015-2016 - Use for prescriptions that were purchased during the years 2015-2016.

Claim Forms

Medical Claim Form
2018 Silver & Fit Claim Form - Use this form for out-of-network claims for plan year 2018.
2017 Silver & Fit Claim Form - Use this form for out-of-network claims for plan year 2017.
Transplant Travel and Lodging Claim form
Dental Claim Form
Our Online Dental Plan Claim Form is being Updated
To have a claim form mailed to you, please contact our Dental Customer Service using the online form below.

Contact Dental Customer Service

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.

Access or Amend your Protected Health

Disclosure Accounting

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

Accounting of Disclosure

Confidential Communications

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

Alternate Address/Location Request

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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