Forms for Members

The forms listed on the menu below are for use by members. These forms are in portable document format (PDF). You may print and copy as needed. Note: Some employers use customized forms or electronic systems. Please check with your Human Resources office.

• Bank Draft Forms
  
  • BlueCare Dental Form (60 KB PDF)
    
    
  • Individual Insurance Products (20 KB PDF): Use this form for Blue Solution PPO, Basic Blue® and Medi-Pak.

• BasicBlue Change Form (61 KB PDF)
  
• Blue Solution PPO Change Form (392 KB PDF)
  
• BlueCare PPO/PPO Plus Change Form (680 KB PDF)
  
• BlueChoice Change Form (392 KB PDF)
  
• BlueSelect Change Request Form (63 KB PDF)
  
• Continuation of Coverage Form (16 KB PDF)
  
• Conversion Policy Change Request (3.2MB PDF)
  
• HSA Blue PPO/HSA Blue PPO Plus Change Form (392 KB PDF)
  
• Medical Claim Form (81 KB PDF)
  
• Non-Underwriting Change Request Form for Current Policy (30 KB PDF)
  
• Other Insurance/Coordination of Benefits (COB) (73 KB PDF)
  
• Prescription Claim Form (882 KB PDF)
  
• Privacy Forms
  
• Student Verification Form (82 KB PDF)
  
• UniqueCare Blue Change Form (1.47MB PDF)
  
• UniqueCare/UniqueCare Preferred Change Form (1MB PDF)
  

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