Excellus Bluecross BlueShield logo
Login | Register | Forgot Username | Forgot Password
Quick Links
Program Offerings
By Phone
By Email
By Mail
Frequently Asked Questions
News & Updates
Print Forms
Compliance Notices
Forms for Members
Forms for Members

Image Link: Get Adobe ReaderUse the links below to print/view copies of our most frequently used forms. All forms are in a PDF format. If you don't already have Acrobat® Reader, you can download it free at Adobe.com


  • $300 BlueHealthy Dollars Reimbursement Form
  • Application for HealthyBlue
  • SimplyBlue
  • SimplyBlue Gym Membership Incentive Reimbursement Form
  • Advance Care Planning for health care proxies, living wills and more
  • Privacy Forms
  • Medical Claim Form
  • Dental Claim Form
  • For Flexible Spending Account (FSA) or Medical Reimbursement Account forms, please visit the EBS-RMSCO website
  • Prescription Drug Claim Form
Home     Contact Us    Print Forms    About Us    Fraud & Abuse    Glossary    Accreditations   
Copyright © 2014, Excellus BlueCross BlueShield, a nonprofit independent licensee of the Blue Cross Blue Shield Association. All rights reserved. View our Privacy Policy for information on how we protect your privacy. Use of this site indicates your acceptance of our Terms of Use. Follow this link to view our 31 county New York State service area. You will need Internet Explorer or Firefox to use the secure features of this site.