Members

Member forms

Note: Some employers use customized forms or electronic systems. Please check with your Human Resources office before using one of these forms.

Authorization for Release of Information [pdf]
Request authorization for someone else to act on your behalf regarding your medical coverage.
Cancel Authorized Representative Appointment Form [pdf]
Cancel a request to authorize someone else to act on your behalf regarding your medical coverage.
Change Form [pdf]
Make changes to existing membership. Send this form to your Human Resources office.
Designation of Authorized Appeal Representative [pdf]
Designation of Authorized Appeal Representative - Non-ERISA [pdf]
Enrollment Form [pdf]
Apply for employee coverage through your Human Resources office. Send this form to your Human Resources office.
Incapacitated Dependent Form [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.
Other Insurance/Coordination of Benefits (COB) [pdf]
Does anyone on your policy have other insurance coverage?

Dental Claim Form [pdf]
For dental claims if your group has dental benefits.
Medical Claim Form [pdf]
Submit claims not filed by a provider.
Prescription claim form [pdf] To make sure eligible claims are paid quickly, please complete and submit this form.
International claim form [pdf]

Individual Request for Accounting (HIPAA) [pdf] Make an individual request for account of certain disclosures of Protected Health Information (PHI) for non-treatment, payment or healthcare operations purposes by BlueAdvantage.
Individual Request Not to Use or Disclose PHI (HIPAA) [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) [pdf]
Make an individual request to correct or amend a record maintained by BlueAdvantage.
Individual Request to Inspect Health Information (HIPAA) [pdf]
Make an individual request to inspect health information maintained by BlueAdvantage.
Request for Confidential Communication (HIPAA) [pdf]
Request confidential communication of Protected Health Information (PHI) from BlueAdvantage.

Continuity of Care Form [pdf]
Exception Letter [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.
Referral Form [pdf]
Your primary care physician should use this form when a referral is required.