Member Forms

Forms for Members

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

Dental Claim FormUse this form to file a claim for dental servicesDownload Form
Medical Claim FormUse 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 FormIf 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 FormIf 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 CoverageThis form notifies us to cancel existing coverage for a spouse or dependent.Download Form
Change Notification FormComplete this form if your name changes through marriage or other event, or if your mailing address changes.Download Form
Continuity of CareThis form is used to request Continuity of Care as outlined under No Surprises Act.

Additional Information

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Continuity of Care for Enrollees Authorization Transfer RequestThis 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
HIPAA Authorization to Release InformationThis form is used for a participant to authorize a release of personal health information including medical, FSA and/or HRA claims, enrollment and reimbursements.Download Form
Request for CancellationUse this form to cancel your coverage if your ID number begins with ZSD or ZSM.Download Form

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