Forms library
Blue Care Network forms
Enrollment forms
- BCN 65 Enrollment form (PDF)
- OneBlue Enrollment form (PDF)
- PersonalPlus Enrollment form (PDF)
- Authorization Agreement for Automatic Payments form (PDF)
Benefit management forms
- Online Coordination of Benefits form
– For online updating of COB information - Coordination of Benefits Questionnaire (PDF)
– To print and then mail or fax to update COB information - Member Reimbursement form (PDF)
– For medical claims that you’ve paid - Member Billing form (PDF)
– For medical claims that need to be paid - Physician Selection form (PDF)
– To print and then mail or fax to change your PCP - Medco Health Home Delivery
Pharmacy Service Order Form (PDF)
– To mail order prescription drugs - Medco Prescription Drug Reimbursement Form (PDF)
– For prescription drug claims that you’ve paid - BlueCard Worldwide International Claim Form (PDF)
– For out-of-state medical claims that you’ve paid
Advance directive forms
- Acceptance by Patient Advocate form ( PDF)
- Durable Power of Attorney for Health Care form (PDF).
- Patient’s Advance Directive form (PDF)
Privacy practice forms
- Access form (PDF)
- Accounting of Disclosures form (PDF)
- Amendment form (PDF)
- Authorization form — Protected Health Information (PDF)
- Authorization form — Psychotherapy Notes ( PDF)
- Authorization Revocation form (PDF)
- Confidential Communications form (PDF)
- Confidential Communications Revocation form (PDF)
- Privacy Complaint form (PDF)
- Restriction Request form (PDF)
page modified 02/26/2010