Downloadable Forms

Print, fill out, and fax or mail in these forms. They are provided in Adobe Acrobat PDF format. If you do not have Acrobat Reader, download it free of charge from Adobe's site.

• Standard Claim Form (PDF)

• BlueCard Worldwide® International Claim Form (PDF)

• Prescription Drug Claim Form (PDF)

• PrimeMail Prescription Drug Mail-Order Form (PDF) — English

• PrimeMail Prescription Drug Mail-Order Form (PDF) — Spanish

• Group Enrollment/Change Application (PDF)

• Student Certification Form (PDF)

• Request for Coverage for Mentally or Physically Impaired Dependents (PDF)

• Coordination of Benefits Form (PDF)

• Medicare Coordination of Benefits Form (PDF)

• Away From Home Care® Guest Membership Application (PDF) — for HMO members only

• Power of Attorney for Health Care Form (PDF) — Designate someone you trust to make health care decisions if you are unable to do so. Follow instructions on the form.

• Standard Authorization Form and other HIPAA Privacy Forms

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