Forms

We've gathered our forms in one place to make it easier to find the one you need.

Application Forms

2024 Blue Option Application

Authorization Forms

Authorization to Disclose Protected Health Information to a Third Party

Your privacy is important to us. In accordance with state and federal laws, we don't share protected health information (PHI) without your consent. Use this form to authorize the release of PHI to a third party. Having this form on file will allow us to discuss your coverage with the person you list, without you having to give permission each time you want that person to contact us on your behalf.

Health and Wellness Authorization Form

We offer a variety of disease and health education programs for the entire family. Please complete this authorization form to participate.

Reimbursement Forms

COVID-19 At-Home Test Member Reimbursement Form Dental Reimbursement Form

Use this form to receive your dental reimbursement. Please note that you have 12 months from the date of service to submit this form.

Claim Forms

Claim Form

There may be times when you travel outside our service area or receive emergency services out of network and wish to file a claim. This is the form you use.