Need a claims form? If you use a provider or hospital that participates in the Service Benefit Plan network, you will not have to fill out any claim forms - the provider will take care of it for you. In situations where you use a provider outside of the network, receive care overseas or require prior approval for a medication, you will need to complete and file a claim form to be reimbursed by your health plan.

To download these forms online, choose from the menu below.

Health Benefits Claim Form

English [PDF 24 KB]

En Español [PDF 332 KB]

Dental Benefits Claim Form

English [PDF 76 KB]

Retail Pharmacy Claim Form

English [PDF 164 KB]

En Español [PDF 40 KB]

Mail Service Prescription Drug Form
(Standard Option only)

English [PDF 95 KB]

Overseas Medical Claim Form

English [PDF 328 KB]

Overseas Retail Pharmacy Claim Form

English [PDF 164 KB]

En Español [PDF 40 KB]

Prior Approval Retail Pharmacy Form

FOR STANDARD AND BASIC OPTIONS: To determine which drugs require prior approval forms and to download and print the form(s) click here.

Submit completed health and dental claim forms along with the related itemized bills to the Local Blue Cross and Blue Shield Plan where the care was performed. To access a listing of the addresses and telephone numbers for all Blue Cross and Blue Shield Plans, please visit Contact Us.

All other claim forms along with the related itemized bills should be submitted to the address noted on the claim form.