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Forms

Here you'll find the forms most requested by members. Follow the links below to download the form you need.

Can't view PDF documents? Download Adobe Acrobat®’ Reader.

Administrative and Privacy

Authorization for release of information, designation of a personal representative, and more.

 

Debit Authorization Recurring Payment Authorization
Schedule your payment to be automatically deducted from your bank account.

 

Deceased Member Affidavit
A form used for claim reimbursement by the surviving spouse or next of kin of a deceased subscriber.

 

Direct Pay Application for a Membership Change Pay
A form to make changes to Direct Pay after a membership change due to circumstances such as marriage, divorce, birth of a child, or loss of eligibility.

 

Documentation of Legal Representative Status for Member
A form documenting the legal authority of an individual to act on a member’s behalf in making decisions about the member’s health care.

 

Member’s Request for an Accounting of Disclosures
A form to request accounting of certain disclosures of your protected health information.

 

Member’s Designation of an Authorized Representative
A form designating an individual as your authorized representative, who may discuss and receive information regarding your health care coverage provided through Blue Cross Blue Shield of Massachusetts.

 

Member’s Request to Amend Protected Health Information
A form to request an amendment to Protected Health Information (PHI) that Blue Cross Blue Shield of Massachusetts maintains in a designated record set.

 

Permission for One-Time Disclosure of Information
A form authorizing Blue Cross Blue Shield of Massachusetts to send specific information to a specific individual.

 

Renewal Audit Package
You and your dependents must live in Massachusetts to renew your individual health plan with Blue Cross Blue Shield of MA. Use this form to show your eligibility.

 

Request for Access to or Copies of Protected Health Information in Designated Record Set
A request form to inspect or obtain copies of your protected health information in the designated record set that Blue Cross and Blue Shield of Massachusetts maintains.

 

Retaining Coverage for Disabled Dependent Child
A form to request coverage a psychologically or physically disabled dependent child.

 

Student Certificate Affidavit
A form that certifies that your child is a full-time student at an accredited school. This allows them to continue to be eligible for health coverage under your policy.

 

Student Medical Leave Affidavit Form
This form certifies that your student dependent is on a medically necessary leave of absence from a post-secondary school.

 

Transgender Services
A form detailing how to request Prior Authorization, or pre-approval, before gender affirming (transgender) services.

Health Plans—Miscellaneous

Dental claims, subscriber submit claim, Medicare Part D appointment of representative, and more.

 

Blue Cross Blue Shield Global Core®
The Blue Cross Blue Shield Global Core form is used to submit institutional and professional claims for benefits for covered services received outside the United States, Puerto Rico, and the U.S. Virgin Islands.

 

International Claim Form
A form for submitting a medical claim when the care is received outside of the U.S., Puerto Rico, and the U.S. Virgin Islands.

 

Continuity of Care Request Form
Complete this form if your doctor is leaving our network and you're receiving treatment for a serious, chronic, or acute medical condition. You may qualify to continue your in-network care for a defined period of time or treatment.

 

Continuity of Care - For Members with a New Hampshire PCP
Our tiered or limited-network plans include a benefit for certain members with a serious health condition, such as cancer or cystic fibrosis.

 

Continuity of Care Form for Plans That Include Tiered-Provider and Limited-Provider Networks
Our tiered or limited-network plans include a benefit for certain members with a serious health condition, such as cancer or cystic fibrosis.

 

Dental Claim Form
A form for submitting a dental claim with instructions on filing a claim.

 

Enhanced Dental Benefits Enrollment Form
Your dental coverage policy must include Enhanced Dental Benefits in order to be eligible for coverage.

 

Medex®´ Subscriber Claim Form
A form for submitting a claim for Medex subscribers with instructions on filing a claim.

 

Subscriber Claim Form
A form for submitting a medical claim with instructions on filing a claim.

 

Transition of Care for New Members
Use this form if you want Blue Cross Blue Shield of Massachusetts to consider short-term coverage, at the in-network level of benefits, with your current out-of-network provider. This gives you some time to transition your care to an in-network provider.

Please note: This form does not apply to Medicare HMO Blue® or Federal Employee Plan (FEP) members. *Blue Cross refers to Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross and Blue Shield of Massachusetts HMO Blue®, Inc., and/or Massachusetts Benefit Administrators LLC, based on Product participation. MPC_061319-2B-2 (11/19) Transition of Care

 

Vision Claim Form
A form for submitting a vision claim, with instructions for filing a claim.

Health and Wellness

Fitness Reimbursement Form
A form to claim your reimbursement on qualified health club membership fees.

 

Fitness Reimbursement Form* (Spanish)
A form to claim your reimbursement on qualified health club membership fees.

 

Living Healthy Smoke-Free—Break Away from the Pack Brochure
20 facts about smoking, reasons to quit, and smoking myths.

 

Weight-Loss Reimbursement Form*
A form to claim your reimbursement on a qualified weight-loss program.

 

Weight-Loss Reimbursement Form* (Spanish)
A form to claim your reimbursement on a qualified weight-loss program.

 

*Reimbursements vary. Please refer to your Summary of Benefits to confirm your reimbursement amount.

Pharmacy

Pharmacy claim form and request for Prior Authorization form.

 

Express Scripts®´´, Inc. Prescription Drug Claim Form
To request reimbursement for a prescription from Express Scripts, you must download, print, fill out this form, and submit it together with your receipts to Express Scripts.

 

Massachusetts Standard Form for Medication Prior Authorization Requests
Your doctor can use this form to request prior authorization or an exception to have your medication covered.

Tax Forms

Qualifying members will receive tax forms that serve as proof of health insurance coverage.

Form 1099-HC

We'll provide the 2020 Form 1099-HC to qualifying members who were enrolled in a Blue Cross Blue Shield of Massachusetts plan at any time during the calendar year. If you qualify, you'll receive your form:

  • Via mail, postmarked by January 31, 2021
  • On their MyBlue account, added on January 31, 2021

View Sample Form 1099-HC

To see your Form 1099-HC from the last two years, sign in to MyBlue and select tax forms

Learn more about the Form 1099-HC

04-1045815 is the Federal Tax ID (FID) for Blue Cross Blue Shield of Massachusetts for Health Care tax filing purposes.

You won't receive a Form 1095-HC if:

  • You're under 18 years old
  • You have a dental and/or vision-only plan through Blue Cross
  • You're enrolled in Medex®' or one of our Medicare Advantage plans

If you haven't received your 1099-HC by the first week of February, 2021, please call Member Service at the number on the front of your ID card.

Form 1095-B

We'll provide the 2020 Form 1095-B to qualifying members who were enrolled in a Blue Cross Blue Shield of Massachusetts plan at any time during the calendar year. The form will be postmarked by January 31, 2021.

Learn more about the Form 1095-B

Your Form 1095-B states which months in 2020 you had health care coverage that meets the minimum essential coverage standards set by the federal government under the Affordable Care Act.

You won't receive a Form 1095-B if:

  • You're a member of a self-funded plan
  • You're a member with dental-only and/or vision-only plans through Blue Cross
  • You're enrolled in Medicare Part B or one of our Medicare Advantage plans
  • You're enrolled in a Health Savings Account plan
  • You're enrolled in wellness programs that are part of minimum essential coverage

If you haven't received your 1095-B by the first week of February, 2021, please call Member Service at the number on the front of your ID card.

Additional Tax Forms

In addition to Form 1099-HC and Form 1095-B, there are other health care-related tax forms that you won’t receive from Blue Cross. The deadline to provide these forms to qualified members is January 31.

Form 1095-A

Form 1095-A, or the Health Insurance Marketplace Statement, is for people who have health insurance through the Massachusetts Health Connector or an ACA Marketplace plan. This form will be provided to qualified members by their plan.

If you have a health plan through the Massachusetts Health Connector and haven’t received your Form 1095-A by January 31, visit Health Care Connector

Form 1095-C

Form 1095-C is for people who receive health insurance from their employer. This form will be provided to qualified members by their employer.

If you have employer-provided health insurance and haven’t received your Form 1095-C by January 31, please contact your employer or HR department.

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ATTENTION: If you speak a language other than English, language assistance services are available to you free of charge. Call 1-800-472-2689 (TTY: 711).

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación llamada 1-800-472-2689 (TTY: 711 ).

ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID chamar  1-800-472-2689 (TTY: 711 ).

ATTENTION : si vous parlez français, des services d’assistance linguistique sont disponibles gratuitement. Appelez le Service adhérents au numéro indiqué sur votre carte d’assuré appel 1-800-472-2689  (TTY : 711 ).

注意:如果您讲中文,我们可向您免费提供语言协助服务。请拨打您 ID  卡上的号码联系会员服务部 通话 1-800-472-2689(TTY  号码:711 )。

ATANSYON: Si ou pale kreyòl ayisyen, sèvis asistans nan lang disponib pou ou gratis. Rele nimewo Sèvis Manm nan ki sou kat Idantitifkasyon w lan (Sèvis pou Malantandan Rele 1-800-472-2689 TTY: 711 ).

LƯU .: Nếu quý vị n.i Tiếng Việt, c.c dịch vụ hỗ trợ ng.n ngữ được cung cấp cho quý vị miễn ph.. Gọi cho Dịch vụ Hội vi.n theo số tr.n thẻ ID của quý vị Cuộc gọi 1-800-472-2689 (TTY: 711 ).

ВНИМАНИЕ: если Вы говорите по-русски, Вы можете воспользоваться бесплатными услугами переводчика. Позвоните в отдел обслуживания клиентов по номеру, указанному в Вашей идентификационной карте вызов  1-800-472-2689 (телетайп: 711 ).

ការជូនដំណឹង៖ ប្រសិនប. ើអ្នកនិយាយភាសា ខ្មែរ សេ  វាជំនួយភាសាឥតគិតថ្លៃ គឺអាចរកបានសម្  រាប ់អ្នក។ សូមទូរស័ព្ទទ ៅផ ្នែ កសេ  វាសមា  ជិកតាមល េខន  ៅល.  ើប ័ណ្ណ សម្  គាល ់ខ្លួ ខ្លួ នរប ស់អ្នក ហៅ  1-800-472-2689 (TTY: 711) ។

ATTENZIONE: se parlate italiano, sono disponibili per voi servizi gratuiti di assistenza linguistica. Chiamate il Servizio per i membri al numero riportato sulla vostra scheda identificativa chiamata  1-800-472-2689 (TTY: 711 ).

참고 : 한국어를 사용하는 경우 언어 지원 서비스를 무료로 사용할 수 있습니다. 신분증에있는 전화 번호 1-800-472-2689 (TTY : 711)로 회원 서비스에 연락하십시오.

ΠΡΟΣΟΧΗ: Εάν μιλάτε Ελληνικά, διατίθενται για σας υπηρεσίες γλωσσικής βοήθειας, δωρεάν. Καλέστε την Υπηρεσία Εξυπηρέτησης Μελών στον αριθμό της κάρτας μέλους σας (ID Card) κλήση 1-800-472-2689 (TTY: 711 ).

UWAGA: Osoby posługujące się językiem polskim mogą bezpłatnie skorzystać z pomocy językowej. Należy zadzwonić do Działu obsługi ubezpieczonych pod numer podany na identyfikatorze zadzwoń 1-800-472-2689 (TTY: 711 ).

ध्यान दें: य दि  आप ह िन् दी बोलते ह ैं, तो भा षा  सहाय  ता  सेवा एँ, आप के लि ए नि :शुल्क  उपलब्ध ह ैं। सदस्य  सेवा ओं को आपके आई.डी. कार  ्ड पर दि ए गए नंबर पर कॉल करें  कॉल 1-800-472-2689 ( टी .टी .वा ई.: 711).

ધ્યાન આપો:  જો તમે ગુજરા તી બોલતા  હો, તો તમને ભા ષા કીય  સહાય  તા  સેવા ઓ વિ ના  મૂલ્યે  ઉપલબ્ધ છે. તમા રા  આઈડી કાર  ્ડ પર આપેલા  નંબર પર Member Service  ને કૉલ કરો કૉલ કરો 1-800-472-2689 (TTY: 711).

PAUNAWA: Kung nagsasalita ka ng wikang Tagalog, mayroon kang magagamit na mga libreng serbisyo para sa tulong sa wika. Tawagan ang Mga Serbisyo sa Miyembro sa numerong nasa iyong ID Card tumawag 1-800-472-2689 (TTY: 711 ).

お知らせ:日本語をお話しになる方は無料の言語アシスタンスサービスをご利用いただけます。ID カードに記載の電話番号を使用してメンバーサービスまでお電話ください 呼び出す 1-800-472-2689(TTY: 711 )。

ACHTUNG: Wenn Sie Deutsche sprechen, steht Ihnen kostenlos fremdsprachliche Unterstützung zur Verfügung. Rufen Sie den Mitgliederdienst unter der Nummer auf Ihrer ID-Karte an Anrufen 1-800-472-2689 (TTY: 711 ).

ຂໍ້ຄວນໃສ່ໃຈ: ຖ້າເຈົ້າເວົ້າພາສາລາວໄດ້, ມີການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາໃຫ້ທ່ານໂດຍບໍ່ເສຍຄ່າ. ໂທ ຫາ ຝ່າຍບໍລິການສະ ມາ ຊິກທີ່ໝາຍເລກໂທລະສັບຢູ່ໃນບັດຂອງທ່ານ ໂທ 1-800-472-2689 (TTY: 711).

BAA !KOHWIINDZIN DOO&G&: Din4 k’ehj7 y1n7[t’i’go saad bee y1t’i’ 47 t’11j77k’e bee n7k1’a’doowo[go 47 n1’ahoot’i’. D77 bee an7tah7g7 ninaaltsoos bine’d44’ n0omba bik1’7g7ij8’ b44sh bee hod77lnih call 1-800-472-2689 (TTY: 711).

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks of Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. ®´´ Registered Marks, TM Trademarks. and SM Service Marks are the property of their respective owners. © 2020 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.