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Forms and Resources

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Forms & Resources for Guests

Applications:

  • For Customers under the age of 65 – Health
  • For Customers under the age of 65 – Dental
  • For Customers age 65 and older – Health
  • For Customers age 65 and older – Dental

Sure Pay Authorization Form:

  • Form to transfer your monthly payment directly to your BCBSAZ account
  • Electronic fund transfer (EFT) form for DentalPlus

Rates:

  • Quick Quote for Customers under the age of 65
  • Rate Sheet for Customers under the age of 65
  • Rate Sheet for Customers age 65 and older

Claims:

  • Provider Appeal and Grievance Quick Reference Guide
  • Corrected Claims Information

Receiving Care While Away From Home:

  • For PPO Members
  • For HMO (BlueSelect) Members

Privacy:

  • BCBSAZ Confidential Information Release Form      Español
  • BCBSAZ Confidential Information Release Form for HIV Related Information
  • HIPAA Notice of Privacy Practices

Commission/Compensation:

  • Sales Compensation Information

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