Print Forms

To submit a claim electronically, please login and go to Submit Claims page.

• Medical or Vision Claim Form Open a PDF - Use to submit medical services from a provider, hospital, DME vendor, etc. Also use for vision services including eyewear. Do not use to submit prescription drug services. All prescription drug services should be submitted on the prescription drug claim form.
• Prescription Drug Claim Form Open a PDF - Use for prescription drug reimbursement.
• Surprise Medical Bill Certification Form Open a PDF - Use this form if you receive a surprise bill for health care services.
• Dental Claim Form
• International Claim Form Open a PDF - Use to submit expenses incurred from rendering medical services overseas. Claims should not be submitted before the effective date.
• International Claim Form in Spanish Open a PDF
• International Claim Form in European A4 Paper Size Open a PDF

FSA, HRA, and HSA Reimbursement Forms

• Reimbursement Account Forms (FSA/HRA/HSA) - Forms provided by Lifetime Benefit Solutions for Flexible Spending Account, Health Reimbursement Account, and Health Savings Account

General Forms

• Advance Care Planning
• Manage Your Privacy
• Deluxe Item Upgrade Form

Membership & Enrollment Forms

• Adult Disabled Dependent Form Open a PDF
• Away From Home Care Guest Membership Application Open a PDF
• Continuing Coverage for Students on Medical Leave Form Open a PDF
• Dental Coverage Attestation Form Open a PDF
• Dependent Certification Form Open a PDF
• Healthy New York Recertification Open a PDF
• Medical Change Form for Direct Purchase Plans Open a PDF
• Dental Change Form for Direct Purchase Plans Open a PDF
• Prior Coverage Verification Form Open a PDF
• Young Adult Option Certification Form Open a PDF

Reimbursement Forms

• SimplyBlue Gym Membership Incentive Reimbursement Form Open a PDF
• Travel Reimbursement Form Open a PDF

Some forms may not apply to your coverage and benefits. To obtain other forms not listed here, please contact Customer Services.