Forms

Choose a health plan below to download claim forms for medical, dental, vision and prescription coverage, plus other related forms including Protected Health Information (PHI).

Medical: BlueChoice (HMO) BlueChoice Opt-Out Open Access  BlueChoice Opt-Out Plus  BluePreferred  Catastrophic Health Insurance Maryland Point of Service (MPOS)  MediGap Supplemental 65  Personal Comp Preferred Provider Organization (PPO)  Traditional Indemnity for NCA

Dental: view form (all dental plans) Vision: Davis (BlueVision, BlueVision Plus) Select Drug: Prescription Drug Claim Form Prescription Drug Claim Form  (Spanish version) Prescription Mail Order Form

Protected Health Information (PHI): Access to PHI Form Authorization Form for Information Release Accounting of Disclosure Form Revocation Form for Information Release or Personal Representative  Amendment to PHI Form Restrict PHI Access Form Personal Representative Form Terminate Restriction to PHI Form