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.

Pre-Authorized Bank Draft Forms

Choose the pre-authorized monthly bank draft form based on your plan type.

Members with metallic plans (Gold, Silver, Bronze, Catastrophic)(English [pdf, 1262 KB] or Espanol [pdf, 349 KB])
You can email your form to or mail it to Arkansas Blue Cross and Blue Shield, EES Membership Financial, P.O. Box 34320, Little Rock, AR 72203-4320.

For all other members (including dental) [pdf, 975 KB]
Use this form for all dental and non-metallic medical plans. You can fax your form to 501-378-2475 or mail it to Arkansas Blue Cross and Blue Shield, Attn: Cashiers (Drafts), P.O. Box 3590, Little Rock, AR 72203.


If you receive a paper bill after you submit your bank draft form, then we are still processing your auto-draft request. You will need to use one of the other payment options to pay your bill. Your bank draft should be effective the following billing period once your auto-draft form is processed. If you have any questions please call the phone number listed on your bill or the back of your Member ID card.

Change Forms

Use these forms to request a change to your current policy, such as name changes, deductible amounts, dependent status and more.

Claim Forms

We want to pay your eligible claims as fast as possible, so use these forms to submit claims.

Privacy Forms

These printable forms allow you to exercise your privacy rights in the most efficient manner. By printing, completing and sending these forms to the Privacy Office, your request will be processed efficiently because we will have the information needed to fulfill the request.

Other Forms