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Forms and Resources for Members

Forms & Resources for Members

Applications:

For Customers under the age of 65 [PDF]
For Customers age 65 and older [PDF]

Sure Pay Authorization Form:

Rates:

Claims:

Medical Claim Form [PDF]
International Claim Form[PDF] Español [PDF]
Pharmacy Claim Form [PDF]
Pharmacy Compounded Medication Claim Form [PDF]

Receiving Care While Away From Home:

For PPO Members [PDF]
For HMO (BlueSelect) Members [PDF]

Privacy:

BCBSAZ Confidential Information Release Form [PDF] Español [PDF]
BCBSAZ Confidential Information Release Form for HIV Related Information [PDF] Español [PDF]
HIPAA Notice of Privacy Practices [PDF]

Commission/Compensation:

Sales Compensation Information [PDF]

Appeals & Grievances:

Health Coverage Appeal Information Packet [PDF]
Appeals Request Form [PDF]
Provider Cert Form for Expedited Review [PDF]

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