Forms
You may download and print forms or you may request forms to be mailed to you.
Downloadable Forms
Medical Claim Forms
Pharmacy Claim Forms
Dental and Vision Claim Forms
International Claim Forms
To submit a claim online, visit Blue Cross Blue Shield 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
- Authorization of Designated Appeals Representative (ADAR) Form
- Authorization of Designated Appeals Representative ACT 68 (ADAR) Form
- Member Appeals Form
- Member Appeals Form ACT 68
Check It Out® Application
Flexible Spending Account (FSA) Forms
HIPAA
- HIPAA Notice of Privacy Practices
- Member authorization form
- Group certification form
- Group health plan representatives authorized to receive member information
- Appeals authorization form for traditional/indemnity lines of business
Fraud
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.