Forms for Members

The forms listed on the menu below are for use by members. These forms are in portable document format (PDF). You may print and copy as needed. Note: Some employers use customized forms or electronic systems. Please check with your Human Resources office.

When you sign up for our free, pre-authorized monthly bank draft program you don’t have to write checks, keep bills or buy stamps. Bills are paid even when you’re away, and there is never risk a lapse in coverage. Affidavit (10 KB PDF) Individual Insurance Products (135 KB PDF): Use this form for all Individual and Family health/dental plans. Use these forms to request a change to your current policy, such as name changes, deductible amounts, dependent status and more. BlueCare Dental Change Form (151 KB PDF) Underwriting Change Form (503 KB PDF) Medi-Pak Change Form (254 KB PDF) Newborn and Adopted Child Change Form (303 KB PDF) Non-Underwriting Change Form (528 KB PDF) We want to pay your eligible claims as fast as possible, so use these forms to submit claims. Accident Form for Dental Injury (10 KB PDF) BlueCard Subscriber Claim Form (51 KB PDF) Dental Claim Form (622 KB PDF) HSA Hospital Indemnity Rider Claim Form (23 KB PDF) International Claim Form (30 KB PDF) International Claim Form (Spanish) (50 KB PDF) Medical Claim Form (81 KB PDF) Prescription Claim Form (882 PDF) These printable forms allow you to exercise your privacy rights in the most efficient manner. By printing, completing and sending these forms to the Privacy Office, your request will be processed efficiently because we will have the information needed to fulfill the request. Authorization for Release Form (5 KB PDF): You have the right to authorize Arkansas Blue Cross to disclose information regarding claims, payments or other communications to any person or entity. HIPAA PHI Disclosure Form for Over Age 65 Products (38 KB PDF) HIPAA PHI Disclosure Form for Under Age 65 Products (41 KB PDF) Request for Accounting (14 KB PDF): You have the right to request a listing of any disclosures we have made of your protected health information for purposes other than payment or health-care operations. Request for Confidential Communications (19 KB PDF): You have the right to ask us to keep communications with you confidential and to ask us to communicate in an alternate manner. Request for Restrictions (25 KB PDF): You have the right to request that we restrict the use of your protected health information for payment and health-care operations. Request to Correct or Amend Record (18 KB PDF): You have the right to request that any information we created about you be amended if you believe that it is incorrect. Request to Inspect Health Information (60 KB PDF): You have the right to inspect or get a copy of records we maintain about you in a designated record set and which we used to make a decision about you. Continuation of Coverage Form (64 KB PDF) Other Insurance/Coordination of Benefits (COB) (585 KB PDF): We want to pay your eligible claims as fast as possible, so please fill out this form to let us know what other insurance you may have. Prescription Mail Service Order Form (599 KB PDF): If your policy has a mail-order drug benefit, use this form to order new and/or refill mail service prescriptions Student Verification Form (82 KB PDF): Dependents over the maximum dependent age but who are enrolled in an accredited educational institution may be eligible for coverage.