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Documents & Forms

We've put together the most common documents and forms you might need for things like filing claims or reviewing your coverage. Start by choosing what kind of insurance you have from the list below.

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Medicare Advantage (BlueAdvantage) Not sure if this is your plan? Medicare Advantage includes BlueAdvantage ^SM Diamond, Ruby, Garnet and Sapphire which should be listed on your Membership ID card.

Annual Notice of Changes

The Annual Notice of Changes describes the changes to your plan’s costs and benefits from the previous year.

2025 BlueAdvantage Emerald Notices of Non-Renewal

Benefits & Coverage

These documents contain information about your benefits, network and coverage.

Billing

Use this form if you'd like BlueCross to accept bank draft payments.

Claims

Use this form if you'd like to submit a claim.

Enrollment

Use these resources to help you enroll in a plan.

Evidence of Coverage

Download a complete list of your plan's coverage, cost and benefits, also called your Evidence of Coverage.

Grievances & Appeals

Use these forms to file an appeal about coverage or payment decision, or to file a grievance if you have concerns about your plan, providers or quality of care.

Pharmacies & Prescriptions

These documents offer information about your covered drug benefits.

Summary of Benefits

Download a simplified list of your plan's benefits and coverage, also called the Summary of Benefits.

Your Rights

You'll find notices and forms in this section to help you understand your rights and responsibilities, and make requests related to those rights.

Appointment of Representative Form Use this form to let someone represent you for a claim, appeal or grievance for your Medicare Advantage plan.
Notice of Privacy Practices
Request Interpreter Services in Another Language
Request Personal Representative Form Use this form to give someone permission to talk with us about your benefits.
Basic Access Account Authorization form
Full Access Account Authorization form

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Web Content Viewer

Documents & Forms

Medicare Advantage (BlueAdvantage) Not sure if this is your plan? Medicare Advantage includes BlueAdvantage SM Diamond, Ruby, Garnet and Sapphire which should be listed on your Membership ID card.

Medicare Advantage (BlueAdvantage) Not sure if this is your plan? Medicare Advantage includes BlueAdvantage ^SM Diamond, Ruby, Garnet and Sapphire which should be listed on your Membership ID card.