Forms

Your privacy is important to us. In accordance with state and federal laws, we don't share protected health information (PHI) without your consent. Use this form to authorize the release of PHI to a third party. Having this form on file will allow us to discuss your coverage with the person you list, without you having to give permission each time you want that person to contact us on your behalf.

We offer a variety of disease and health education programs for the entire family. Please complete this authorization form to participate.

Use this form to receive your dental reimbursement. Please note that you have 12 months from the date of service to submit this form.

There may be times when you travel outside our service area or receive emergency services out of network and wish to file a claim. This is the form you use. 

Use this form if you need to appeal a claim on behalf of someone else.

This form offers you the convenience of ordering your prescription drugs by mail.

There may be times when you need to file for a reimbursement regarding your prescription(s). This is the form you use.

You can use this form to:

• Cancel your plan on the next due date.
• Add or change your bank draft.

This form gives us information about any other health coverage you may have that can affect how we pay benefits. This is also known as Coordination of Benefits (COB). You can complete this form online by logging into My Health Tookit®.

The information requested on this form aids in providing BlueChoice HealthPlan the necessary information to make a coverage determination.

This form is for people with an acute injury or illness. Members or covered dependents need to get approval for this short-term benefit.