Claim Forms

Authorize Release of Protected Health Information (PHI)

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. Please note: Consent is needed for any dependent over the age of 18.

Member Appeal Form

An appeal is a request to change a previous adverse decision made by your health plan. You or your representative (Including a 
physician on your behalf) may appeal the adverse decision related to your coverage. If you elect to have a representative file an appeal on your behalf, you will also need to complete the Authorization Form for Appeals by Personal Representative below. You can access the appeal form here.

Appeal Authorization Form

Sometimes we need a representative (Including a physician on your behalf) to file an appeal for us. To authorize anyone, other than yourself, to file an appeal on your behalf the Publix Authorization Form for Appeals by Personal Representative Form must be completed. You can access the form here.

Health Benefits Claim Form

Use this form when filing a claim for services received from an out-of-network physician or health care professional. You can access the claim form here.

International Claim Form

For outpatient services and doctor care or inpatient care not arranged through the Service Center, you may need to pay upfront. Complete a Blue Cross Blue Shield Global Core International claim form and send it with the bill(s) to the Service Center (the address is on the form). You can also submit your claim online or through the Blue Cross Blue Shield Global Core mobile app. You can access the claim form here.

Subrogation Form

Did you receive health care services related to an accident? Or services that could be related to an accident? You may need to complete this questionnaire. It helps us determine which party is responsible for paying your claims. It’s important that you submit this information promptly so that we may process your claims. You can access the subrogation form here.

Other Health Insurance

Do you or anyone else covered on your policy have any other health insurance? You may need to complete this questionnaire. It helps us determine if we are your primary or secondary insurance payer. It’s important that you submit this information promptly so that we may process your claims. You can access the Other Health Insurance form here.

Mental Health Release of Information

Your privacy is important to us. In accordance with state and federal laws, we don’t share protected health information (PHI) without your consent. In addition to the Protected Health Information form, this form must be completed before we, including Companion Benefit Alternatives (CBA), may discuss your mental health with anyone other than yourself.    You can access the CBA Authorization to Disclose Protected Health Information (PHI) to a Third Party form here.

Request Continuation of Care from a Non-Network Provider

If circumstances change and a member’s provider is not in network or is no longer in network, we strive to make the transition seamless. A member with these circumstances can ask to have benefits with his or her original provider paid at the in-network level for a limited time. You can access the Transition of Care/Continuation of Care Request Form here.