Forms & Resources
- 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 BillsYour Rights and Protections Against Surprise Medical Bills in Spanish
- Member Prior Authorization List
- Customers Over the Age of 652020 BCBSAZ Rate Justification
- PPO Members
- Transporting & Lodging Benefit
- Accounting Request FormAmendment RequestAuthorized Representative Designation FormBCBSAZ Confidential Information ReleaseBCBSAZ Confidential Information Release in SpanishBCBSAZ Confidential Information Release - HIV Related in SpanishBCBSAZ Confidential Information Release - HIV Related InformationConfidential Communications FormHIPAA Notice of Privacy PracticesOptum Pharmacy Confidential Information Release FormPHI Access Request FormPrivacy Complaint FormRestriction Request FormConfidential Information Release Forms alone do not grant authorization to your representative to file appeals on your behalf. If you wish to have someone request an appeal on your behalf please submit a completed Confidential Information Release Form along with either an Authorized Representative Designation Form or Healthcare Power of Attorney.