Form Library
Need a claims form? If you use a provider or hospital that participates in the Service Benefit Plan network, you will not have to fill out any claim forms - the provider will take care of it for you. In situations where you use a provider outside of the network, receive care overseas or require prior approval for a medication, you will need to complete and file a claim form to be reimbursed by your health plan.
To download these forms online, choose from the menu below.
Health Benefits Claim Form
English [PDF 79 KB]En Español [PDF 194 KB]Dental Benefits Claim Form
English [PDF 125 KB]Retail Pharmacy Claim Form
English [PDF 175 KB]En Español [PDF 74 KB]
Mail Service Prescription Drug Form (Standard Option only)
English [PDF 175 KB]
Overseas Medical Claim Form
Overseas Retail Pharmacy Claim Form
Prior Approval Retail Pharmacy Form
FOR STANDARD AND BASIC OPTIONS: To determine which drugs require prior approval forms and to download and print the form(s) click here .
Submit completed health and dental claim forms along with the related itemized bills to the Local Blue Cross and Blue Shield Plan where the care was performed. To access a listing of the addresses and telephone numbers for all Blue Cross and Blue Shield Plans, please visit Contact Us .
All other claim forms along with the related itemized bills should be submitted to the address noted on the claim form.
Page last updated: January 11, 2012