Special Enrollment Application

Do you need 2021 coverage? If so, please review, fill out and submit this application. 

Authorization to Disclose Protected Health Information

You can use this form to give us permission to release information to someone else. Please note that if you're a parent of a minor child, you can still get information about your child without having to complete this form.

Change Request Form

You can use this form to:

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

Claim 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. 

Dental Reimbursement Form

Use this form to receive your dental reimbursement. Please note that you have 3 months from the date of service to submit this form. 

Designation of Authorized Representative of Appeal Form

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

International Claim Form

International Claim Form in Spanish

Use this form to submit institutional and professional claims for covered services you receive outside the United States, Puerto Rico, Jamaica and the U.S. Virgin Islands. 

Health and Wellness Authorization Form 

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

HSA Bank Application

HSA Bank is an independent company that offers health savings account (HSA) administration on behalf of BlueChoice HealthPlan.

Online Other Health Coverage Questionnaire

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^®.

Pharmacy Mail-Order Form 

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

Pharmacy Reimbursement Form

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

Request for Benefit Extension for an Incapacitated Dependent

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

Transition of Care Form

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