Web Content Viewer - Fixed Context

Web Content Viewer - Fixed Context

Web Content Viewer - Fixed Context

Forms

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

Web Content Viewer - Fixed Context

Downloadable Forms

Medical Claim Forms

Dental and Vision Claim Forms

International Claim Forms

To submit a claim online, visit BlueCross BlueShield Global Core®, or print out the form below.

NOTE: International Claim Forms should be sent to:

Service Center

P.O. Box 2048
Southeastern, PA 19399

Appeals Forms

Check It Out® Application

Flexible Spending Account (FSA) Forms

HIPAA

Claim forms are for claims processed by Capital BlueCross within our 21-county service area in Central Pennsylvania and Lehigh Valley. If you receive services outside Capital BlueCross' 21-county area, another Blue Plan may have an agreement to process your claims, even though your coverage is with Capital BlueCross. You should obtain claim forms from the local Blue Plan that processes your claims. The Capital BlueCross 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.