We recently updated our forms and applications. Please select the link for the applicable benefits in which you want to enroll and complete the application.
Medical (Non-Medicare) and Dental Benefits Enrollment
Medicare Advantage Plan and Dental Benefits Enrollment Form
Continuation of Coverage Form
Statement of Health Form
Small Employer Exemption (SEE) Form
Non-Medicare Medical Claim Form:
To obtain a member-submitted claim form or international claim form, please visit the Highmark website at www.highmarkbcbs.com or contact customer service at 866.763.9471 for assistance.
Pharmacy Claim Form:
To obtain a pharmacy reimbursement form, please login to your account at www.express-scripts.com or contact customer service at 800.939.3781 for assistance.
Other Health Plan Related Forms:
Domestic Partnership Statement of Financial Interdependence Form
Health Benefits Automatic Credit Reduction Form
Protected Health Information Release Form