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

Check It Out® Application

Flexible Spending Account (FSA) Forms

HIPAA

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.