Types of forms
- Prescription claim form
- Prescription claim form - Spanish
- Vision claim form
If you choose to see an out-of-network provider, submit your itemized receipt(s) along with the out-of-network reimbursement form. You will be reimbursed the allotted amount based on your benefits.
- Authorization for release of information
- Designation of authorized appeal representative
- Designation of authorized appeal representative - Non-ERISA plan
- Request for confidential communication of protected health information
- Request for restrictions
Individual request not to use or disclose (restrict) health information or to end restriction on use or disclosure of health information maintained by BlueAdvantage Administrators of Arkansas
- Request to inspect health information
Individual request to inspect health information maintained by BlueAdvantage Administrators of Arkansas
- Individual request for accounting
Certain disclosures of protected health information for non-treatment, payment, or health care operations purposes made by BlueAdvantage Administrators of Arkansas
- Request to correct or amend record
- Request for continuity of care
- Authorized representative cancellation form
- Exception letter
- Medical claim form