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360° Health®

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

Download Commonly Requested Forms

PW_A086783
 
Claim Forms
Dental Claim Form
Member Health Expense Report
Prescription Drug Claim Form
To find this form, members must visit the Express Scripts website after login to their health plan site. Click the link in the Refill a Prescription section after login. On the Express Scripts site, select the Claims Reimbursement Form from the Printable Forms section.
Routine Vision Service Report
 
COBRA Forms
Refer to the COBRA Implementation Paperwork Guide for instructions and forms
 
Consumer Choice
Provider Nomination Form Instructions
Provider Nomination Form
Questions and Answers about Consumer Choice Option
 
FSA Forms
Dependent Care Claim Form
Health Care Claim Form
 
HDHP HSA
Employer Group HSA Initiation Form
HSA Application – Group Participant
HSA Application Addendum
 
HIPAA Forms
Individual Authorization Form
Conditioned Authorization
Instructions for Completing Conditioned Authorization
 
Member Enrollment Forms
Member Enrollment Application – Small/Large Group (2-99 employees)
Member Enrollment Application – Large Group (100+ employees)
Notice of Special Enrollment Rights
 
Membership Forms
Certification of Dependency
Handicapped Disabled Member Form
Large Group – Cancellation Authorization
Large Group – Master Application
PCP Selection Form
Small Group – Cancellation Authorization
Small Group – Member Enrollment Change Form
Small Group – Master Application
 
Miscellaneous Forms
Employer

Large and Small Group Supply Order Form

Member

Group Life & Disability - Change of Beneficiary 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.