Medi-Pak Supplement

General Medi-Pak Supplement documents

Medicare Eligible On or After 01/01/2020 Application

Medicare Eligible prior to 01/01/2020 Application

Member bank draft forms

If you have individual coverage and a monthly premium, you can pay it through a pre-authorized bank draft. To get started, choose a bank draft form below based on your plan type.

• For individual members (including dental) [pdf]
  Use this form for all dental and non-metallic individual medical plans. You can mail your form to Arkansas Blue Cross and Blue Shield, Attn: Cashiers (Drafts), P.O. Box 3590, Little Rock, AR 72203. You can also fax it to the number listed on the form.

Important

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.

Claim forms

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

• Non-metallic claim form [pdf]
• Accident form for dental injury [pdf]
• BlueCard subscribers claim form [pdf]
• Dental claim form [pdf]
• International claim form [pdf]

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 [pdf]
  You have the right to authorize Arkansas Blue Cross Blue Shield to disclose information regarding claims, payments or other communications to any person or entity.
• HIPAA PHI disclosure form for Medicare Supplement products [pdf]
• Request for accounting [pdf]
  You have the right to request a listing of any disclosures we have made of your protected health information for purposes other than payment or healthcare operations.
• Request for confidential communications [pdf]You have the right to request that we keep communications with you confidential and communicate in an alternate manner
• Request for restrictions [pdf]
  You have the right to request that we restrict the use of your protected health information for payment and healthcare operations.
• Request to correct or amend record [pdf]
  You have the right to request that any information we created about you be amended if you believe that it is incorrect.
• Request to inspect health information [pdf]
  You have the right to inspect or get a copy of records we maintain about you in a designated record set and which we used to make a decision about you.

Other forms

• Designation of authorized appeal representative [pdf]
• Expedited appeal request form [pdf]
• Other insurance/coordination of benefits (COB) [pdf]
  Does anyone on your policy have other insurance coverage?