Vision Claim Form
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.
Mail order is easy and convenient. You can have your prescriptions delivered right to your home.
90 Day Mail Order Prescription Form
You can order certain specialty medications for chronic conditions quickly and conveniently through our Specialty Pharmacy Program.
Prescription Drug Form
Get reimbursed for the amounts you’ve paid for the diagnosis, cure, mitigation, treatment or prevention of disease.
Health Care FSA Claim Form
Use this form to request reimbursement for care of Dependent children under 13.
Dependent Care FSA Claim Form
This form will initiate reimbursements for qualified dental and vision expenses.
Limited-Purpose FSA Claim Form
Reimbursement form for eligible HRA Plan expenses.
Health Care HRA 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.
Network P&S PPO In Network Benefit Request Form
Network E PPO In Network Benefit Request Form
Request for coverage of non-covered medications.
Pharmaceutical Exception Request Form
Authorization for BlueCross BlueShield of Tennessee to Accept Bank Draft Payments for Health Insurance Premiums.
Individual Products Bank Draft Form
Authorization for BlueCross BlueShield of Tennessee to Accept Bank Draft Payments for Health Insurance Premiums
Marketplace Bank Draft Form
Direct Deposit Authorization Form for reimbursement of payments you made directly to providers.
HRA/FSA Direct Deposit Forms
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)
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.
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.
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.
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
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
Use this form to designate another person to access and update your protected health information.
Personal Representative Request
Use this form to make an official complaint about our privacy practices or compliance.
Use this form to request that we restrict use or disclosure of your protected health information. * Requires Approval.