HealthyBlue PPO Gold $1,000 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 (MD, DC and Northern VA)
For services received in the MD, DC and Northern Virginia CareFirst service area.
|Medical Claim (Other Service Areas)
For services received in areas other than the MD, DC and Northern Virginia
CareFirst service area.
|International Claim Form
(For care received out of network area)
|Transition of Care|
|Membership Change Form for Maryland Residents (Off-Exchange)
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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