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Medical Forms

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. If you are enrolling in Life Insurance and Disability Income benefits you must also complete the Life Insurance and Disability Income (LIDI) Metlife Enrollment Change form.

Enrollment Forms:

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

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

Protected Health Information Release Form