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Notes


Members can use the claim forms for services rendered by in-area or out-of-area non-participating providers. Participating providers are responsible for filing claims for their services. Claim forms should not be used for services rendered through any discount Dental or Vision program or for the Options program for alternative therapies. The discount is applied by the provider at the time of service for such programs.

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BluePreferred Claim Forms

If you need a form that is currently not available online, please call Member Services at the telephone number on your ID card. To see all forms, please return to Forms Home Page.

Medical Claim (MD, DC and Northern VA)

For services received in the MD, DC and Northern Virginia CareFirst service area.

View Form
Medical Claim

For services received in areas other than the MD, DC and Northern Virginia
CareFirst service area.

View Form
Membership Change Request

If you buy insurance through your employer, please contact your employer to make
changes. Changes will not be processed unless received from your employer.This
form is for D.C. and Maryland members only

View Form
eBilling (Automatic Debit)

View Insert
BlueCard Worldwide International Claim

(For care received out of network area)

View Form
Coordination of Benefits

(Update your information on My Account)

View Form
Student Certification

For Maryland residents (excluding Prince George's and Montgomery Counties)

View Form
Student Certification

For Maryland (Prince George's and Montgomery Counties only), D.C. and VA residents

View Form
Disability Certification

For Maryland residents (excluding Prince George's and Montgomery Counties)

View Form
Disability Certification

For Maryland (Prince George's and Montgomery Counties only), D.C. and VA residents

View Form
HRA Reimbursement Form

View Form
HRA Direct Deposit Form

View Form
New HSA/HRA Debit Card Request Form

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Debit Card Validation Form

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Information Sheet

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Forms

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