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HealthyBlue Dual/Triple Option 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.

Medical Claim
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.
eBilling (Automatic Debit)
BlueCard Worldwide International Claim
(For care received out of network area)
Coordination of Benefits
(Update your information on My Account)
Student Certification
For Maryland residents (excluding Prince George's and Montgomery Counties)
Student Certification
For Maryland (Prince George's and Montgomery Counties only), D.C. and VA residents
Disability Certification
For Maryland residents (excluding Prince George's and Montgomery Counties)
Disability Certification
For Maryland (Prince George's and Montgomery Counties only), D.C. and VA residents
Information Sheet
Maryland Advance Directive
Transition of Care Form

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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