Documents & Forms Results

BlueCard Worldwide International Claim Form - Spanish

Reclamo Internacional

Nondiscrimination Complaint Form

Prescription Drug Claim Form

Dental Claim Reimbursement Form

Subscriber Medical Claim Form - Spanish

Formulario de solicitud de reembolso presentado por el miembro

Worldwide Emergency or Urgent Care Benefit Claim Form - Medicare

For Medicare Supplement, Medicare Cost, and Medicare Advantage members. Use this form to request reimbursement for emergency or urgent care services received outside the United States.

Dental Claim Reimbursement Form (Medicare)

Member Submitted Reimbursement Request Form - Medicare

For Medicare Supplement, Platinum Blue (Cost), and Medicare Advantage members. Use this form to request reimbursement of member costs incurred for services received from a provider that does not contract with any Blue Cross and Blue Shield licensee.

Medicare Organ Transplant Transportation and Lodging Reimbursement Form

This form may be used for reimbursement of expenses as the result of a Medicare-approved organ transplant.