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.
|BlueCard Worldwide International Claim
(for members receiving care outside of the U.S.)
|Disability Dependent Certification Form|
|HIPAA Authorization Form for Information Release|
|HIPAA Designation of Personal Representive
(expires when policy terminates)
|HIPAA Revocation Form for Information Release
(expires a year from date of signature)
|Medical Claim Form|
|Vision Claim Form|
|PCP Selection - Point of Service (POS)
(existing members can change their PCP online)
PDFs require Adobe Acrobat Reader to open. Download it free from the Adobe site.