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.NF-42 NF-43
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
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.
- Application for Group Enrollment
- Group Member Enroll or Change Enrollment Form
- Application for New ASO Groups Enrolling 2-50 Subscribers
- PlusBilling® Form
You may use the links below to download the Appeals Forms.
- Authorization of Designated Appeals Representative (ADAR) Form for Traditional/Indemnity Lines of Business
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
- Enrollment or Change Enrollment
- Health Care and Limited-Purpose FSA Debit Card
- Request for Direct Deposit of FSA Claims Reimbursement
- Claim Reimbursement Voucher
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.