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.
Membership 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?
Claim forms
- 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]
Privacy forms
- 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.
Other forms
- 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.