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BlueChoice Opt-Out Plus
If you need a form that is currently not available online, please call Member Services at the telephone number on your ID card.
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Medical Claim (MD, DC and Northern VA) |
For services received in the MD, DC and Northern Virginia CareFirst service area. |
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Medical Claim |
For services received in areas other than the MD, DC and Northern Virginia CareFirst service area. |
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Vision - Davis |
(BlueVision, BlueVision Plus) |
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BlueCard Worldwide International Claim |
(For care received out of network area) |
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Student Certification |
For Maryland residents (excluding Prince George's and Montgomery Counties) |
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Student Certification |
For Maryland (Prince George's and Montgomery Counties only), D.C. and VA residents |
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Disability Certification |
For Maryland residents (excluding Prince George's and Montgomery Counties) |
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Disability Certification |
For Maryland (Prince George's and Montgomery Counties only), D.C. and VA residents |
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New HSA/HRA Debit Card Request Form |
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Debit Card Validation Form |
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| 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. |
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Viewing and printing this document requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.
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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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.
® Registered trademark of the Blue Cross and Blue Shield Association. ®' Registered trademark of CareFirst of Maryland, Inc. |
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This site is best viewed in IE 7.0 or higher or Firefox 3.0 or higher. |
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