Download Forms

 

Claim Forms  

Blue View Vision Out-of-Network Reimbursement Claim Form  

Blue Vision Routine Vision Service Report Form  

Member Health Expense Report  

Dental Service 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 website, select the Claims Reimbursement Form from the Printable Forms section. 

BlueCard Worldwide International Claim Form  

BlueCard Worldwide International Claim Form (en Español )  

 

HIPAA Forms  

Individual Authorization Form  

Psychotherapy Notes Authorization Form  

 

USG HIPAA Forms  

Board of Regents Member Authorization Form Instructions  

Board of Regents Member Authorization Form  

 

Federal Employee Program (FEP) HIPAA Forms  

FEP Member Authorization Form – Instructions  

FEP Member Authorization Form  

 

Life & Disability Forms  

GGL Beneficiary Change Form  

Life & Disability Forms  

 

Miscellaneous Forms  

Large Group Member Change Form  

Small Group Member Change Form  

Individual Enrollment and Change Forms  

Continuation of Care Coverage  

If your doctor will no longer be in the BCBSGA network, you may have the option to continue to receive care for a limited time. Care should be related to treatment already begun for this spell of illness/problem or if you are pregnant and began prenatal care. Complete this form and provide to your doctor who will fill out and return to BCBSGA. You will receive a decision in the mail about continuing care with that doctor.  

Certificate of Dependency Form  

Handicap/Disabled Member Certification Form  

 

Consumer Choice  

Q&A about Consumer Choice  

Provider Nomination Form  

 

FSA Forms  

Health Care Claim Form  

Dependent Care Claim Form  

 

Away From Home Care Guest Membership Forms  

General Information About Guest Membership  

Guest Membership Application Interest Letter  

Guest Membership Application  

Guest Membership Application Signature Form