## Commonly used forms

 

### Medical claim form

Request reimbursement for eligible health care services received.



 

[View form - English](https://bluecrossmn.widen.net/content/fdhrvwvdeq/original/member-claim-form-f7403r13-web.pdf)

[View form - Spanish](https://bluecrossmn.widen.net/content/wizicv2pry/original/f7403r13-formulario-de-reclamo-del-membro.pdf)

 

 

 



### Eyewear reimbursement form (Medicare)

Request reimbursement for eligible eye care services you've received. For members of Medicare plans.



 

[View form](https://bluecrossmn.widen.net/content/pcee10wohq/original/medicare-eyewear-reimbursement-form.pdf)

 

 

 



### Vision claim form (Commercial)

Request reimbursement for eligible eye care services you've received. For members with an individual and family or employer vision plan.



 

[View form](https://bluecrossmn.widen.net/content/nemjbzopag/original/p11ga_16350107-vision_claim_form_cl00191.pdf)

 

 

 



### Authorization for Disclosure of Health Information online form

Authorize Blue Cross to give information about you to someone else.



 

[View form](/member-resources/authorization-disclosure-health-information)

 

 

 



### Premium payment direct deposit form

Set up automatic monthly premium payments from your checking or savings account with Pay-It-Easy.



 

[View form](https://bluecrossmn.widen.net/content/skomhd5hag/original/pay-it-easy-automatic.pdf)

 

 

 



### BlueRide transportation request form

Rides to eligible medical appointments for members with a Medical Assistance (Medicaid) plan.\*



 

[View form](/our-plans/medical-assistance-medicaid/medical-assistance-resources/blueride-transportation)

 

 

 



 

 



 

 

## Search by plan type

 

### Medicare

 

[Search Medicare](/forms/search?keywords=&audience%5B1436%5D=1436&plan_type%5B1051%5D=1051)

 

 

 



### Individual & Family 

 

[Search Individual & Family ](/forms/search?keywords=&audience%5B1436%5D=1436&plan_type%5B1066%5D=1066)

 

 

 



### Medical Assistance (Medicaid)

 

[Search Medical Assistance (Medicaid)](/forms/search?keywords=&audience%5B1436%5D=1436&plan_type%5B1056%5D=1056)

 

 

 



### Dental & vision

 

[Search dental & vision](/forms/search?keywords=&audience%5B1436%5D=1436&plan_type%5B1061%5D=1061&plan_type%5B1071%5D=1071)

 

 

 



 

 



 

## Search by category

 

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### Benefits & coverage

 

[Search benefits & coverage](/forms/search?keywords=&category%5B1366%5D=1366)

 

 

 



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### Shopping & learning

 

[Shopping & learning](/forms/search?keywords=&category%5B1386%5D=1386)

 

 

 



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### Enrollment & eligibility

 

[Search enrollment & eligibility](/forms/search?keywords=&category%5B1351%5D=1351)

 

 

 



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### Financial information

 

[Search financial information](/forms/search?keywords=&category%5B1356%5D=1356)

 

 

 



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### Claims & appeals

 

[Search claims & appeals](/forms/search?keywords=&category%5B1361%5D=1361)

 

 

 



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### Legal & regulatory

 

[Search legal & regulatory](/forms/search?keywords=&category%5B1381%5D=1381)

 

 

 



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### Prescription & pharmacy

 

[Search prescription & pharmacy](/forms/search?keywords=&category%5B1376%5D=1376)

 

 

 



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### Provider information

 

[Provider information](/forms/search?keywords=&category%5B1371%5D=1371)

 

 

 



 

 



 

 

 

 

## Support

 

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### Need help?

If you have questions about a form or can not find what you need, call the customer service number on the back of your member ID card.



 

[Contact us](/contact-blue-cross-minnesota)

 

 



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### Member FAQs

Get answers to frequently asked questions about your Blue Cross or Blue Plus health plan.



 

[View frequently asked questions](/member-resources/member-faqs)

 

 



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### Member login

Log in to your member account to get access to forms and documents specific to your health plan.

[Create account](https://members.bluecrossmn.com/)



 

[Log in](https://identity.bluecrossmn.com/u/login?state=hKFo2SBhZTZlaEU1c3ZJQkpubGtKaGphenNtVHNXcXNHb2Z1SaFur3VuaXZlcnNhbC1sb2dpbqN0aWTZIGlaMEtHNG8tREZwTHFXY3RpVDVic0JFNndTMTczY1Joo2NpZNkgcDZ2elJyNHBQRUFvWkM4d0NVQWNMU3VNSHU2OEJKMm4)

 

 



 

 



 

 

 

\*Restrictions and Conditions apply.