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Members

Forms

You have two ways to access the forms needed to submit claims to Capital BlueCross and its wholly owned subsidiary, Capital Advantage Insurance Company1. You may download and print PDF forms from this site or you may request to have forms mailed to you at your home or business.

Medical Form Search

Which medical form you need depends upon the product in which you are enrolled. To determine the form that you need, simply enter the three-character alpha prefix found on your insurance card at the beginning of your Identification Number. The results will provide a link to the correct form which you can download and print as well as a form to request copies via U.S. Mail.

If you have trouble using the Form Search or do not receive the result you expected, contact us. We'll be happy to help you get the form you need.

1 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.


Other Downloadable Forms

Claim Forms (Dental and Vision)

International Claim Forms

NOTE: International Claim Forms should be sent to:

BlueCard Worldwide Service Center
P.O. Box 261630
Miami, FL 33126  USA

Enrollment Forms

You may use the links below to download the Enrollment Forms. You may also submit a request to receive the Enrollment / Change Application form via standard mail.

Appeals Forms

You may use the links below to download the Appeals Forms.

Reconsideration Inquiry

You may use the link below to download the PersonalBlue Reconsideration to request a review of a preexisting condition determination.

Check It Out Application

An automated payment option that will deduct your Capital BlueCross premium directly from your bank account.

SimplySelect FSA Forms

HIPAA Privacy Forms

You may use the link below to view and/or download* the current communications/forms regarding Member HIPAA privacy, including our Notice of Privacy Practices.


* You'll need software, like Adobe Reader, installed on your computer to view and print PDF files. You can find and download Adobe's free reader at www.adobe.com.