Forms for Members

The forms listed on the menu below are for use by members. These forms are in portable document format (PDF). You may print and copy as needed. Note: Some employers use customized forms or electronic systems. Check with your Human Resources office before using one of these forms.

• Authorized Representative Appointment Form (67 KB PDF): Request authorization for someone else to act on your behalf regarding your medical coverage.
  
  
• Cancel Authorized Representative Appointment Form (70 KB PDF): Cancel a request to authorize someone else to act on your behalf regarding your medical coverage.
  
  
• Change Form (52 KB PDF): Make changes to existing membership. Send this form to your Human Resources office.
  
  
• CHIP Forms and Information
  
  
• Coordination-of-Benefits (COB) Questionnaire (35 KB PDF): If you or any members of your family have health or dental insurance other than BlueAdvantage, use this form.
  
  
• Dental Claim Form (586 KB PDF): For dental claims if your group has dental benefits.
  
  
• Dental Claim Form - BAA (586 KB PDF)
  
  
• Enrollment Form (46 KB PDF): Apply for employee coverage through your Human Resources office. Send this form to your Human Resources office.
  
  
• Exception Letter (32 KB PDF): Request a pre-service exception to receive network benefit reimbursement for non-network provider services. All requests are subject to medical necessity and coverage guidelines.
  
  
• Incapacitated Dependent Form (100 KB PDF): This form is to be submitted for a request of continuation of coverage for dependents with a mental or physical handicap that have exceeded the student age.
  
  
• Individual Request for Accounting (HIPAA) (6 KB PDF): Make an individual request for account of certain disclosures of Protected Health Information (PHI) for non-treatment, payment or health-care operations purposes by BlueAdvantage.
  
  
• Individual Request Not to Use or Disclose PHI (HIPAA) (8 KB PDF): Request not to use or restrict health information or to end restriction on use or disclosure of health information maintained by BlueAdvantage.
  
  
• Individual Request to Correct or Amend a Record (HIPAA) (7 KB PDF): Make an individual request to correct or amend a record maintained by BlueAdvantage.
  
  
• Individual Request to Inspect Health Information (HIPAA) (7 KB PDF): Make an individual request to inspect health information maintained by BlueAdvantage.
  
  
• Medical Claim Form (43 KB PDF): Submit claims not filed by a provider.
  
  
• Prescription Claim Form (882 KB PDF): This claim form should not be used by CHIP policyholders. Prescription drug claims for CHIP policyholders should be filed using the Medical Claim Form linked above.
  
  
• Referral Form (36 KB PDF): Your primary care physician should use this form when a referral is required.
  
  
• Request for Confidential Communication (HIPAA) (6 KB PDF): Request confidential communication of Protected Health Information (PHI) from BlueAdvantage.
  
  
• Student Questionnaire (86 KB PDF): If your dependent has reached the maximum dependent age under your health plan but is enrolled as a full-time student at an accredited educational institution, use this form.