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HIPAA Member Authorization Form and Instructions

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The HIPAA privacy rules limits the use and disclosure of a member's protected health information without an authorization from the individual or their legal/personal representative. If you desire to share protected health information with another party, please fill out this form and contact customer service at the toll-free number on your member identification card.

Member Claim Form

Usually providers of health care bill Blue Cross directly for services to you and your enrolled dependents. However, if you have to submit a claim for medical services you must complete this form.  Please see page 2 of this form for instructions on how to complete this form and submit it to Blue Cross.

Maximim Copayment Liability Notification Form

This form is for members to complete who have reached the maximum copayment limit for the year on their HMO or POS plans. When a member or family reaches that amount they are not required to pay further copays for most services for the remainder of that year. The form needs to be sent to BlueCross, who will notify the medical group.

Prescription Drug Claim Form

If you purchase a prescription drug from a Non-Participating Pharmacy, you will need to submit this form to the Blue Cross Pharmacy Department.  Refer to page 1 of this form for instructions.

Your Blue Cross of California prescription drug benefit includes a mail order option. If you would like to order prescription drugs through the mail, please use this form.

If you have a Flexible Spending Account, use this form to request reimbursement for qualifying medical expenses.  Refer to page 2 for details about eligible expenses.

If you have a Flexible Spending Account and your employer group has selected the Direct Deposit feature (please confirm with your employer before completing this form), use this form to request reimbursement for qualifying medical expense that will go directly into your bank account.