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Forms

Medi-Gap/Supplemental 65 and Related Forms

If you need a form that is currently not available online, please call Member Services at the telephone number on your ID card.

Form
Form Number
Medical Claim
Authorization to Change
Outpatient Pre-Treatment Authorization
Easy Pay
BlueCard Worldwide International Claim
(for care received out of network area)
Advance Directives
Form Number
As a convenience for members, we are providing links to the Maryland Attorney General's Web site to access information on Advance Directives and Living Wills.
Information Sheet
Forms

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Members can use the claim forms for services rendered by in-area or out-of-area non-participating providers. Participating providers are responsible for filing claims for their services. Claim forms should not be used for services rendered through any discount Dental or Vision program or for the Options program for alternative therapies. The discount is applied by the provider at the time of service for such programs.

 
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Health and Wellness --
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Frequently Asked Questions
Online Tools and Services
Prescription Drugs
Options Discount Program - Alternative Therapies, Vision, Hearing and Other Wellness Services
Employee Education Tools:
Managing Your Care - CareEssentials
Keeping Health Care Affordable
News & Updates

November 20th Wellness WebEx Presentation - Kick the Habit with a Worksite Smoking Cessation Program

Options Discount Program Expands

Maryland Health Insurance Partnership Subsidy Program

Family Coverage Expansion Act

Prescription Drug News

Nutritional Supplements and Over-the-Counter FDA Safety Information

Vitality Member Newsletter

News Archives

Latest News

 
 
Serving Maryland, the District of Columbia and portions of Virginia. CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueChoice, Inc., an affiliate company, also offers health benefit products and services on this site.

CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association.

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