Forms

Please select a form from the table below. These forms are all PDFs and will require Adobe Acrobat Reader to open. Download it free from the Adobe site.

Forms
BlueCard Worldwide International Claim PDF icon
(for members receiving care outside of the U.S.)
Disability Dependent Certification Form PDF icon
HIPAA Authorization Form for Information Release PDF icon
HIPAA Designation of Personal Representive PDF icon
(expires when policy terminates)
HIPAA Revocation Form for Information Release PDF icon
(expires a year from date of signature)
Medical Claim Form PDF icon
Vision Claim Form PDF icon
PCP Selection - Point of Service (POS) PDF icon
(existing members can change their PCP online)

PDF PDFs require Adobe Acrobat Reader to open. Download it free from the Adobe site.