download forms for individuals and families

Below are our most frequently requested forms in Acrobat PDF files. For other forms please contact us by email, call us at 800-400-1246 or go to the links page to access carrier websites.

Third Party authorization to Disclose Personal and Health Information

Select Carrier:

• Blue Shield of California
• Blue Cross of California
• HSA Bank
• HSA Partners

• Blue Shield of California - Individual and Family Plans
  • Blue Shield of CA HIPAA Privacy Form
  • Individual Application
  • Individual/Family Application
  • Change Request Form
  • Easy Pay Authorization Form
  • Medical Claim Form
  • Retail Pharmacy Claim Form
  • Mail Order Pharmacy Claim Form

• Blue Shield of California Life & Health -- Short Term Health Plans
  • Blue Shield Life and Health HIPAA Privacy Form
  • Short Term Application Option 1
  • Short Term Application Option 12

• Blue Shield of California Medicare Supplement Plans
  • Application for Medicare Supplement (over age 65)
  • Easy Pay(Bank Draft) Authorization

• Blue Cross of California - Individual and Family Plans
  • Blue Cross HIPAA Privacy Form
  • Application Form (under age 65)
  • Change Request
  • Auto Payment Request Form (Bank Draft)
  • Medical Claim Form
  • Retail Pharmacy Drug Clain Form
  • Mail Order Pharmacy Drug Claim Form

• Blue Cross of California - Medicare Supplement
  • Application for Classic Plans A, C, F, I & J
  • Application for Smart Choice Plan F

• Blue Shield of California HSA Partner
  • Wells Fargo Bank Individual/Family Enrollment Form

• Blue Cross of California HSA Partner
  • Chase HSA Individual/Family Enrollment Package

• HSA Bank
  • Application
  • Beneficiary Form
  • Custodial Agreement

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