Forms library
Blue Care Network forms
Enrollment forms
- BCN 65 Enrollment form (PDF)
- OneBlue Enrollment form (PDF)
- PersonalPlus Enrollment form (PDF)
- Authorization Agreement for Automatic Payments form (PDF)
Benefit management forms
- Online Coordination of Benefits form
- Coordination of Benefits Questionnaire (PDF)
- Member Reimbursement form (PDF)
- Member Billing form (PDF)
- Physician Selection form (PDF)
- Medco Health Home Delivery Pharmacy Service Order Form (PDF)
- BlueCard Worldwide International Claim Form (PDF)
Advance directive forms
- Acceptance by Patient Advocate form ( PDF)
- Durable Power of Attorney for Health Care form (PDF).
- Patient’s Advance Directive form (PDF)
Privacy practice forms
- Access form (PDF)
- Accounting of Disclosures form (PDF)
- Amendment form (PDF)
- Authorization form — Protected Health Information (PDF)
- Authorization form — Psychotherapy Notes ( PDF)
- Authorization Revocation form (PDF)
- Confidential Communications form (PDF)
- Confidential Communications Revocation form (PDF)
- Privacy Complaint form (PDF)
- Restriction Request form (PDF)
Family Health Center forms
Privacy practice forms
- Authorization Form — Protected Health Information (PDF)
- Authorization Form — Psychotherapy Notes (PDF)
- Authorization Revocation Form (PDF)
- Access Form (PDF)
- Amendment Form (PDF)
- Restriction Request Form (PDF)
- Confidential Communications Form (PDF)
- Accounting of Disclosures Form (PDF)
- Privacy Complaint Form (PDF)
page modified 10/05/2009