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Member Forms

Download and print commonly used forms. All forms are in PDF format. Download Acrobat Reader.

Member Forms

FORM
DESCRIPTION
Accident Questionnaire
Use this form to provide the details of an accident and any third-party liability for the purpose of determining payment of your claim.
Automatic Withdrawal Authorization
Many people find it convenient to have their health coverage premiums withdrawn from their bank account automatically. Print and complete this form, so you never have to write a check for premiums again.
Cancel Spouse or Dependent Coverage
This form notifies us to cancel existing coverage for a spouse or dependent.
Certification of Dependent Eligibility
When children reach college age, many of them can remain on a parent's coverage if they are enrolled as full-time students. Use this form to verify your student’s enrollment status.
Change Notification Form
Complete this form if your name changes through marriage or other event, or if your mailing address changes.
Dental Claim Form
Use this form to file a claim for dental services.
Dependent Student Leave of Absence Certification
Use this form to continue coverage if a dependent child attending an accredited postsecondary educational institution is required to take a medical leave of absence from school that would cause loss of eligibility.
HIPAA Authorization to Release Information
This form is used for a participant to authorize a release of personal health information including medical, FSA and/or HRA claims, enrollment and reimbursements.
Insurance Questionnaire
This form is used to verify any other healthcare coverage you may currently have or have had in the past. Information on this form is important to ensure you receive the most out of your benefits.
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.
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.
Request for Cancellation
Use this form if you wish to cancel a benefit plan.
 
 

FlexShare Forms

FORM
DESCRIPTION
Auto Pay Authorization
This form authorizes certain claims processed through your Blue Cross Blue Shield of Wyoming health insurance policy to be automatically withdrawn from your healthcare FSA or HRA.
Change in Status for FSA
Use this form to notify us of changes that affect your FSA healthcare or dependent care spending accounts.
Change in Status Matrix for FSA
Explains qualifying events that allow you to change your election for FSA healthcare or dependent care.
Change in Status for HRA
Use this form to notify us of changes that affect your HRA election.
Direct Deposit Authorization
Submit this form to have your FlexShare reimbursement directly deposited to your personal checking or savings account.
HIPAA Authorization to Release Information
This form is used for a participant to authorize a release of personal health information including medical, FSA and/or HRA claims, enrollment and reimbursements.
Request for Reimbursement
Complete this form to file a FSA healthcare, dependent care or HRA claim.

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