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Health & Wellness

A total-health solution that surrounds everyone with the help they need to live healthier, feel better and save money doing it.

Individual and Family Forms

PW_B147972
 
Agreement for List Bill – Individual
Authorization Form - Individual
Authorization Form – Individual (Spanish)
Automatic Draft Request – Individual
Certificate of Dependency Form
Conditioned Authorization Form
Conditioned Authorization Form - Instructions
County Codes
Dental Application - Individual/Family
Direct Deposit Form
 
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Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.