Medical Plan Forms

  • Medical Plan Claim Form – Complete this form when submitting a medical claim for services rendered by a provider who does not belong to the Blue Cross Blue Shield network. (Blue Cross Blue Shield network providers will submit your claim on your behalf.)
  • Appointment of Authorized Representative Form – Use this form to authorize another person to act on your behalf in matters related to filing/appealing claims or privacy of protected health information.
  • HIPAA Authorization Form – Use this form to authorize other person(s) and/or organization(s)  to use and/or disclose your health information
  • SavRx Mail Order Prescription Form – Use this form to order prescriptions through the SavRx Mail Order Program.
  • HEALTHY LIFE Reference Card – Bring this reference card to your HEALTHY LIFE doctor’s appointment to make sure your exam covers the require