Print Forms

Claim Forms

To submit a claim electronically, please login and go to Submit Claims page.

• Medical or Vision Claim FormOpen a PDF - Use to submit medical services from a provider, hospital, DME vendor, etc. Also use for vision services including eyewear. Do not use to submit prescription drug services. All prescription drug services should be submitted on the prescription drug claim form.
• Prescription Drug Claim FormOpen a PDF - Use for prescription drug reimbursement.
• Surprise Medical Bill Certification FormOpen a PDF - Use this form if you receive a surprise bill for health care services.
• Dental Claim Form
• International Claim FormOpen a PDF - Use to submit expenses incurred from rendering medical services overseas. Claims should not be submitted before the effective date.
• International Claim Form in Spanish Open a PDF
• International Claim Form in European A4 Paper SizeOpen a PDF

FSA, HRA, and HSA Reimbursement Forms

• Reimbursement Account Forms (FSA/HRA/HSA) - Forms provided by Lifetime Benefit Solutions for Flexible Spending Account, Health Reimbursement Account, and Health Savings Account

General Forms

• Advance Care Planning
• Manage Your Privacy
• Deluxe Item Upgrade Form

Membership & Enrollment Forms

• Adult Disabled Dependent FormOpen a PDF
• Away From Home Care Guest Membership ApplicationOpen a PDF
• Continuing Coverage for Students on Medical Leave FormOpen a PDF
• Dental Coverage Attestation Form Open a PDF
• Dependent Certification FormOpen a PDF
• Healthy New York Recertification Open a PDF
• Medical Change Form for Direct Purchase PlansOpen a PDF
• Dental Change Form for Direct Purchase PlansOpen a PDF
• Prior Coverage Verification FormOpen a PDF
• Young Adult Option Certification FormOpen a PDF

Reimbursement Forms

• SimplyBlue Gym Membership Incentive Reimbursement FormOpen a PDF
• Travel Reimbursement FormOpen a PDF

Some forms may not apply to your coverage and benefits. To obtain other forms not listed here, please contact Customer Services.