Members
Member forms - Employer coverage
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.
Change forms
Use these forms to request a change to your current policy, such as name changes, deductible amounts, dependent status and more.
Claim forms
We want to pay your eligible claims as fast as possible, so use these forms to submit claims.
- Accident form for dental injury [pdf]
- BlueCard subscribers claim form
[pdf]
- Dental claim form [pdf]
- HSA hospital indemnity rider claim form [pdf]
- International claim form [pdf]
- Metallic medical claim form [pdf]
- Non-metallic claim form [pdf]
- Prescription claim form [pdf]
- Vision claim form
[pdf]
If you choose to see an out-of-network provider, submit your itemized receipt(s) along with the out-of-network reimbursement form. You will be reimbursed the allotted amount based on your benefits.
Privacy forms
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
[pdf]
You have the right to authorize Arkansas Blue Cross Blue Shield to disclose information regarding claims, payments or other communications to any person or entity. - HIPAA PHI disclosure form [pdf]
- Request for accounting
[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 healthcare operations. - Request for confidential communications [pdf] You have the right to request that we keep communications with you confidential and communicate in an alternate manner
- Request for restrictions
[pdf]
You have the right to request that we restrict the use of your protected health information for payment and healthcare operations. - Request to correct or amend record
[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
[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.
Other forms
- Continuity of care form [pdf]
- State of Arkansas Continuation of Coverage Election Form [pdf]
- Designation of authorized appeal representative [pdf]
- Member appeal submission form [pdf]
- Other Insurance/Coordination of Benefits (COB)
[pdf]
Does anyone on your policy have other insurance coverage? - Prescription mail service order form [pdf] If your policy has a mail-order drug benefit, use this form to order new and/or refill mail service prescriptions
- Proof of incapacity of a dependent - Physician's form [pdf]
- Proof of incapacity of a dependent - Policyholder's form [pdf]