Forms

You may download and print forms or you may request forms to be mailed to you.

What would you like to do?

Complete the member health equity questionnaire

Your answers to the health equity questionnaire will help us record your cultural and linguistic needs, share those preferences with your providers, develop more inclusive programs and services, educate our workforce, and more respectfully engage with the people and communities we serve.

As a reminder, your privacy is important to us. This optional, secure questionnaire and the information you provide will be protected through our established and tested privacy and digital security policies. This information will not be used to make any decisions about coverage or services. Come back anytime to make updates.

If you have any questions or need help with language assistance, please call the number on the back of your ID card.

Note, if you have dependents who are under the age of 18 or you are a CHIP parent or guardian, you may complete the questionnaire on their behalf.

Submit a claim

Request payment to reimburse an expense covered by your plan.

Capital Blue Cross members can log in to submit medical or international requests electronically.

Use the following forms to download, print, and mail your request.

Set up automatic payment

Set up your automatic premium payment.

Please note this section only applies to Individual Account members that pay directly for their own premiums. This section does not apply for members who receive coverage through their employer.

Permit someone else to receive your information

Give permission for Capital Blue Cross to release your information to a person you name.

Capital Blue Cross members can log in to submit a form electronically.

Or use one of the following forms to download, print, and mail your request.

Submit disability certification for an adult dependent

Use the disability certification form to request coverage for an adult dependent.

Submit enhanced dental benefit form

Capital Blue Cross offers enhanced dental benefits for members with certain chronic health conditions. You can self-submit eligibility based on diagnosis if Capital Blue Cross does not have your diagnosis eligibility on file from medical claims history.

For members with a Capital Blue Cross dental plan, log in to your secure account to submit the enhanced dental benefits form electronically or download and print the form to send to us.

Coverage for enhanced dental benefits is an optional benefit that may not be included in your plan. Consult your Benefits Booklet for benefit details.

Report suspected fraud

We actively protect our members from fraud and abuse. Learn more about how to report suspected fraud.

Learn about privacy practices

Member privacy is important to us. Review our privacy practices or give permission for Capital Blue Cross to release your information to a person you name.

File an appeal or grievance

Members

If you want to question a Capital Blue Cross decision or permit someone to question a decision for you:

Log in to your secure account and submit the CHIP appeals form to appeal one of the following:

  • The outcome of a processed claim.
  • A service that was preauthorized and the authorization was denied.
Providers

If you are submitting a request on behalf of a provider, log in to the secure portal to complete the provider dispute form.

Claim forms are for claims processed by Capital Blue Cross within our 21-county service area in Central Pennsylvania and Lehigh Valley. If you receive services outside Capital Blue Cross' 21-county area, another Blue Plan may have an agreement to process your claims, even though your coverage is with Capital Blue Cross. You should obtain claim forms from the local Blue Plan that processes your claims. The Capital Blue Cross service area includes these counties: Adams, Berks, Centre County, Columbia, Cumberland, Dauphin, Franklin, Fulton, Juniata, Lancaster, Lebanon, Lehigh, Mifflin, Montour, Northampton, Northumberland, Perry, Schuylkill, Snyder, Union and York.