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Claim Forms

Dental Claim Form

Use this form for dental claims, when the claim is not filed through your dentist. Need help? Instructions for completing dental claim forms are also available.
Dental Claim Form

Prescription Drug Form

We call it the GO-510 form.  You’ll use it only for prescription drug claims when the claim is not filed through your pharmacist.
Prescription Drug Form

Medical Claims Forms

We're Sorry - Medical Claims Forms aren’t available online
These official forms use a red ink that cannot be duplicated by regular PC color printers.  We can help with some Instructions for completing medical claim form.  Pre-printed, red-ink CMS forms can be purchased from your local office supply store.  To view a copy of a proper form visit Centers for Medicare and Medicaid Services (CMS) website and choose CMS-1500 Form but remember - a copy of the form printed from their site will result in delayed processing of your claim.


Prescription Forms

Mail Order Prescription Form

Mail order is easy and convenient. You can have your prescriptions delivered right to your home.
90 Day Mail Order Prescription Form

Order Specialty Medications

You can order certain specialty medications for chronic conditions quickly and conveniently through our Specialty Pharmacy Program.
Prescription Drug Form


Financial Arrangement Forms

Flexible Spending Account (FSA) Forms

Health Care FSA Claim Form

Get reimbursed for the amounts you’ve paid for the diagnosis, cure, mitigation, treatment or prevention of disease.
Health Care FSA Claim Form

Dependent Care FSA Claim Form

Use this form to request reimbursement for care of Dependent children under 13.
Dependent Care FSA Claim Form

Limited-Purpose FSA Claim Form

This form will initiate reimbursements for qualified dental and vision expenses.
Limited-Purpose FSA Claim Form

Health Reimbursement Arrangement (HRA) Forms

Health Care HRA Form

Reimbursement form for eligible HRA Plan expenses.
Health Care HRA Form


Exception Forms

PPO In Network Benefit Request Form

Can’t find the specialist you need in your network? Is the doctor you’ve been seeing is no longer in your network?  This form will help you obtain in-network approval prior to getting care.
PPO In Network Benefit Request Form

Pharmaceutical Exception Request Form

Request for coverage of non-covered medications.
Pharmaceutical Exception Request Form


Bank Forms

Individual Products Bank Draft Form

Authorization for BlueCross BlueShield of Tennessee to Accept Bank Draft Payments for Health Insurance Premiums.
Individual Products Bank Draft Form

Marketplace Bank Draft Form

Authorization for BlueCross BlueShield of Tennessee to Accept Bank Draft Payments for Health Insurance Premiums
Marketplace Bank Draft Form

HRA/FSA Direct Deposit Forms

Direct Deposit Authorization Form for reimbursement of payments you made directly to providers.
HRA/FSA Direct Deposit Forms


HIPAA Member Right Forms

Notice of Privacy Practices (NOPP)

This notice describes how health plan information about you may be used and disclosed and how you can get access to this information. It provides a listing of your rights as required under HIPAA.
Notice of Privacy Practices (NOPP)

Access Request

You have a right to look at and get copies of your health plan information, with limited exceptions.
Use this form to request copies of your own protected health information or records in our (or our business associates) designated record set.
Access Request

Amendment Request

You have the right to make a written request to amend your health plan information.
Use this form to request that we amend your protected health information in designated record sets we maintain. *Requires Approval.
Amendment Request

Authorization Form

Use this form to authorize us to use or disclose protected health information for the purpose stated.  It can also be used to authorize another person to disclose protected health information to us.
Authorization Form

Confidential Communications Request

Use this form to request that we use alternative means or send information to an alternative location when communicating about protected health information. You can make this request if you believe that sending your health plan information to you in the normal manner will endanger you.
Confidential Communications Request

Disclosure Accounting Request

Use this form to request an accounting of any disclosures of your protected health information. This accounting will include disclosures made by us (or our business associates) for any reason other than for treatment, payment, or health care operation purposes within the past six years.
Disclosure Accounting Request

Personal Representative Request

Use this form to designate another person to access and update your protected health information.
Personal Representative Request

Privacy Complaint

Use this form to make an official complaint about our privacy practices or compliance.
Privacy Complaint

Restriction Request

Use this form to request that we restrict use or disclosure of your protected health information. * Requires Approval.
Restriction Request

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