Forms & Resources

Update Assigned PCP

Change Request Form

How to Complete Your Out-of-Network Claim Form (Senior Preferred members)

Medical Claim

English
Español

Dental Claim

BlueDental Prevention +1 Submission Form

English

Pharmacy Claim

Pharmacy Compounded Medication Claim

Continuity of Care Form

Autopay Authorization

Customers Age 65 and Older

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

AZ Blue Confidential Information Release

AZ Blue Confidential Information Release in Spanish

AZ Blue Confidential Information Release - HIV Related in Spanish

AZ Blue Confidential Information Release - HIV Related Information

Request for Protected Communications Form

HIPAA Notice of Privacy Practices

Optum Pharmacy Confidential Information Release Form

Request for Health Records

Privacy Complaint Form

Restriction Request Form