Forms

Not sure which health plan you belong to? Go to Finding Your Health Plan, or call Member Services at the telephone number listed on your member ID card.

Medical: BlueChoice (HMO) BlueChoice Opt-Out Open Access BlueChoice Opt-Out Plus BluePreferred Catastrophic Health Insurance Maryland Point of Service (MPOS) MediGap Supplemental 65 Personal Comp Preferred Provider Organization (PPO) Traditional Indemnity for NCA Federal Employee Program

Dental: view form (all dental plans) Vision: Davis (BlueVision, BlueVision Plus) Select Drug: Prescription Drug Claim Form Prescription Drug Claim Form (Spanish version) Prescription Mail Order Form MedWatch Form

Protected Health Information (PHI): Access to PHI Form Authorization Form for Information Release Accounting of Disclosure Form Revocation Form for Information Release or Personal Representative Amendment to PHI Form Restrict PHI Access Form Personal Representative Form Terminate Restriction to PHI Form