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Claims Forms

  • Claim Appeal Form
  • Designation of Authorized Representative to Appeal
  • Dental Services
  • Flexible Spending Account-Dependent Care
  • Flexible Spending Account-Medical Reimbursement
  • Health Benefits within the U.S.- Use this form only when filing a claim for services received from an out-of-network physician or health care professional.
  • Health Benefits Worldwide
  • Health Reimbursement Account
  • Healthy Vision Out of Network
  • Standard Vision Out of Network
  • Prescription Drug Claim Form
  • Mail Service Order Form
  • HIPAA Authorization Form

 

 
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Non-Discrimination Statement and Foreign language Access

An Independent Licensee of the Blue Cross and Blue Shield Association.

The information in My Health Toolkit® can help you understand your health plan benefits. It does not describe all the parts of the plan or guarantee payment, reimbursement or eligibility of coverage. Please refer to your policy for specific benefits.