• Print:
  • Text Size:

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.

PDF

Viewing and printing this document requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.

HealthyBlue 2.0 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

View Form
Health and Wellness Evaluation Form

(for participation-based incentive programs)

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.

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
Information Sheet

View Form
Forms

View Form