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. | Download Form |
| 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 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 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 to Release Information Form | This form is used for a participant to authorize a release of protected health information including medical, FSA and/or HRA claims, enrollment and reimbursements. | 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 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. | |
| Request for Cancellation | Use this form to cancel your coverage if your ID number begins with ZSD or ZSM. | |
| Vision HIPAA Authorization Form | This form is used to authorize Davis Vision to furnish and release protected health information. |
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