Downloadable Forms

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

• Standard Claim Form 

• BlueCard Worldwide® International Claim Form 

• Prescription Drug Claim Form 

• PrimeMail Prescription Drug Mail-Order Form — English 

• PrimeMail Prescription Drug Mail-Order Form — Spanish 

• Group Enrollment/Change Application 

• Student Certification Form 

• Request for Coverage for Mentally or Physically Impaired Dependents 

• Coordination of Benefits Form 

• Medicare Coordination of Benefits Form 

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

• Power of Attorney for Health Care Form  — 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

Back to main UNMH page