Forms for Members
Download and print commonly used forms. All forms are in PDF format. Download Acrobat Reader.
| Dental Claim Form | Use this form to file a claim for dental services | Download Form → |
| Medical Claim Form | Use this form to file a claim for medical services, such as office visits, physical therapy, laboratory service, and radiology services such as X-rays. | Download Form → |
| Prescription Drug Claim Form | If your plan includes the prescription coverage and you are unable to have a prescription claim filed by the pharmacy, use this form to submit a claim for prescription benefits. | Download Form → |
| Vision Claim Form | If your plan includes vision care, use this form to file a claim for services from providers who are out of network. | Download Form → |
| Cancel Spouse or Dependent Coverage | This form notifies us to cancel existing coverage for a spouse or dependent. | Download Form → |
| Change Notification Form | Complete this form if your name changes through marriage or other event, or if your mailing address changes. | Download Form → |
| Continuity of Care | This form is used to request Continuity of Care as outlined under No Surprises Act. | |
| Continuity of Care for Enrollees Authorization Transfer Request | This form is used to request transfer of authorization from a previous insurance carrier to BCBSWY. | |
| Dental Continuation of Care Request Form | This form contains important information about your dental health care provider’s status. | Download Form → |
| Domestic Partner Declaration | Use this form to document a domestic partner that would be eligible to enroll on your health plan. | Download Form → |
| HIPAA Authorization to Release Information Form | This form is used for a participant to authorize a release of protected health information including medical records, claims, enrollment and reimbursements. | Download Form → OR Complete form online by CLICKING HERE → |
| HIPAA Access Request Form | This form is used for an individual requesting to inspect and/or obtain copies of their protected health information or records in BCBSWY’s designated record sets or the designated record sets of BCBSWY’s business associates. | Download Form → |
| HIPAA Accounting Request Form | This form is used for an individual requesting for an accounting of disclosures of protected health information. | Download Form → |
| HIPAA Amendment Request Form | This form is used for an individual requesting to amend protected health information or records in BCBSWY’s designated record sets or the designated record sets of BCBSWY’s business associates. | Download Form → |
| HIPAA Authorization for Release of Substance Abuse Confidential Information Form | This form is used for an individual to authorize BCBSWY to disclose their records that are protected by Federal Confidentiality rules (42 C.F.R. Part 2). | Download Form → |
| HIPAA Authorization Revocation Form | This form is used to revoke or to confirm revocation of an authorization previously given to BCBSWY. | Download Form → |
| HIPAA Complaint Form | This form is used to lodge a complaint about BCBSWY’s privacy practices or compliance | Download Form → |
| HIPAA Confidential Communication Request Form | This form is used to request that BCBSWY use alternative means or an alternative location when communicating about protected health information to avoid endangering an individual. | Download Form → |
| HIPAA Consent Form | This form is used to give consent to BCBSWY’s use and disclosure of an individual’s protected health information to carry out BCBSWY’s payment activities and health care operations. | Download Form → |
| HIPAA Consent Revocation Form | This form is used to revoke or confirm revocation of a consent previously given to BCBSWY. | Download Form → |
| HIPAA Termination of Previously Approved Restrictions on Use and Disclosure of PHI Form | This form is used to request to terminate a previous request to restrict use or disclosure of protected health information, including for treatment, payment, or health care operations. | Download Form → |
| HIPAA Restriction Request Form | This form is used to request restriction of use or disclosure of protected health information, including for treatment, payment, or health care operations. | Download Form → |
Out of State Non-Participating Provider Waiver Form* *Only applicable for members with ZSK and ZSF membership prefixes. | Use this form if you need non-urgent, non-emergency care from a provider outside of Wyoming who is non-participating. | Download Form → |
| Request for Cancellation | Use this form to cancel your coverage if your ID number begins with ZSD or ZSM. | Download Form → |
| Vision HIPAA Authorization Form | This form is used to authorize Davis Vision to furnish and release protected health information. | Download Form → |
Not Finding What You're Looking For?
We're here to help, Monday - Friday 8:00am to 5:00pm
1-800-442-2376
1-800-442-2376
Watch Videos to Learn More
Understanding High Deductible Health Plans
Plus, explore Health Savings Accounts and how to use them.
How to Use Your Health Insurance Plan
Tips and resources to help you get the most from your BCBSWY plan.
How to Find a Health Care Provider Near You
How to search for a doctor, dentist, or other health care professional.