Forms & Resources

How to Complete Your Out-of-Network Claim Form

Medical Claim

Dental Claim

BlueDental Prevention +1 Submission Form

Pharmacy Claim

Pharmacy Compounded Medication Claim

Customers Age 65 and Older

Autopay Authorization

Instructional PDF for Machine Readable Files

Mental Health Parity Disclosure Request Form

Your Rights and Protections Against Surprise Medical Bills

Your Rights and Protections Against Surprise Medical Bills in Spanish

Member Prior Authorization List

Customers Over the Age of 65

2020 BCBSAZ Rate Justification

PPO Members

Transporting & Lodging Benefit

Accounting Request Form

Amendment Request

Authorized Representative Designation Form

BCBSAZ Confidential Information Release

BCBSAZ Confidential Information Release in Spanish

BCBSAZ Confidential Information Release - HIV Related in Spanish

BCBSAZ Confidential Information Release - HIV Related Information

Confidential Communications Form

HIPAA Notice of Privacy Practices

Optum Pharmacy Confidential Information Release Form

PHI Access Request Form

Privacy Complaint Form

Restriction Request Form