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MyBlue offers online tools, resources and services for Blue Cross Blue Shield of Arizona Members, contracted brokers/consultants, healthcare professionals, and group benefit administrators. 24/7 online access to account transactions and other useful resources, help to ensure that your account information is available to you any time of the day or night.

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Forms and Resources

Forms

Applications

Customers Age 65 and older

Claims

How to Complete Your Out-of-Network Claim Form
Medical Claim
Dental Claim
BlueDental Prevention +1 Submission Form
Pharmacy Claim
Pharmacy Claim in Spanish
Pharmacy Compounded Medication Claim

Precertification

Member precertification list

Privacy

Authorized Representative Designation Form
BCBSAZ Confidential Information Release
BCBSAZ Confidential Information Release in Spanish
BCBSAZ Confidential Information Release - HIV Related Information
BCBSAZ Confidential Information Release - HIV Related in Spanish
HIPAA Notice of Privacy Practices
Optum Pharmacy Confidential Information Release Form

*Confidential 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. For more information on which form to use, visit the “What Form Should I Use?” tab to the right.

Rates

Customers Over the Age of 65
QHP Rate Information
2020 BCBSAZ Rate Justification

Receiving Care While Away from Home

PPO Members

Autopay Authorization

Autopay Authorization

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URAC Case Management Accredited Expires 02/01/2021 URAC Health Plan Accredited Expires 02/01/2021 URAC Health Insurance Marketplace Accredited Expires 02/01/2021