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

When you sign up for our free, pre-authorized monthly bank draft program you don’t have to write checks, keep bills or buy stamps. Bills are paid even when you’re away, and there is never a risk of a lapse in coverage.

Individual Insurance Products

Change Forms

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

Dental Change Form

Underwriting Change Form

Newborn and Adopted Child Change Form

Non-Underwriting Change Form

Claim Forms

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

Accident Form for Dental Injury

BlueCard Subscriber Claim Form

Dental Claim Form

HSA Hospital Indemnity Rider Claim Form

International Claim Form (PDF)

International Claim Form (Spanish) (PDF)

Medical Claim Form

Prescription Claim Form

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.

Authorization for Release Form

HIPAA PHI Disclosure Form for Over Age 65 Products

HIPAA PHI Disclosure Form for Under Age 65 Products

Request for Accounting

Request for Confidential Communications

Request for Restrictions

Request to Correct or Amend Record

Request to Inspect Health Information