BluePreferred Claim Forms - CareFirst BlueCross BlueShield

Forms

BluePreferred

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 (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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Dental Claim

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Vision Claim - Davis

(BlueVision, BlueVision Plus)

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Membership Change Request

If you buy insurance through your employer, please contact your employer to make changes. Changes will not be processed unless received from your employer.
This form is for D.C. and Maryland members only.

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EasyPay (Automatic Debit)

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BlueCard Worldwide International Claim

(For care received out of network area)

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Coordination of Benefits

(Update your information on My Account)

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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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HRA / HSA

Form Number

HRA Reimbursement Form

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HRA Direct Deposit Form

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New HSA/HRA Debit Card Request Form

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Debit Card Validation Form

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Advance Directives

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

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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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	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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