University of California

UNIVERSITY of CALIFORNIA
Other Forms and Information
Medical Claim Form	This form can be used by all UC members to submit claims for non participating providers.
Foreign Claim Form	This form can be used by UC members to submit foreign claims.
Disabled Dependent Certification	This form can be used by UC members to submit certification for an unmarried dependent child who is disabled.
Transition Assistance Form - Inside California	This form should be used by members who are in a course of treatment, or pregnant, whose physician does not participate in the Blue Cross network, or whose medication is not part of the Blue Cross formulary.
Transition Assistance Form - Outside California	This form should be used by members who are in a course of treatment, or pregnant, whose physician does not participate in the Blue Cross network, or whose medication is not part of the Blue Cross formulary.
HIPAA Member Authorization Form	The HIPAA privacy rules limits the use and disclosure of a members protected health information (PHI) without an authorization from the individual or their legal personal representative. This form will need to be filled out by the member to designate anyone other than a UC benefits representative to receive PHI.
How to read your Explanation of Benefits (EOB)	Attached is the EOB brochure which includes a sample EOB and how to locate information on it.
Relay Health	Relay Health offers on-line access to doctors. Listed here are the most current names of network providers who have implemented Relay Health into their medical practices.