Member Forms

HIPAA Notice of Privacy Practices

• Protected Health Information Authorization for Customer Service Inquiries 
• Authorization for Disclosure of PHI Records 
• Access to PHI Records Request 

Find forms for reimbursement of medical vision or dental expenses and other related forms.
 

File Name	Description
Grievance & Appeal Form - HMO	Used to appeal a coverage decision and request formal written review of how a claim was processed.
Grievance & Appeal Form - Non-HMO	Used to appeal a coverage decision and request formal written review of how a claim was processed.
Appointment of Representative Form	Used by members to appoint someone to represent them in connection with a specific claim. Once completed, contact Member Services for Submission Instructions.
Claim Form - Medical	Used to submit a claim directly to Florida Blue.
Claim Form - Medical International	Used to submit a claim for international medical services directly to Florida Blue.
Claim Form - Vision	Used to submit a claim for vision services received from an out-of-network provider.
Claim Form - Dental	Find claim forms and brochures for dental services covered by your BlueDental plan.
Claim Form - Prescription Drug	Used to submit a prescription drug claim directly to Florida Blue.
Claim Form - Accident Letter	Used to furnish Florida Blue or Health Options information if you have recently experienced a claim related to an accident.
Protocol Exemption Request Form	Used to submit Protocol Exemption Request for Step-Therapy protocol, click here for instructions.

Find forms for reimbursement of prescription expenses, mail order drugs and authorization requests. Provided to members for their providers to complete and submit for prior authorization. Applies to members with Prescription Benefits that require prior authorization or prior coverage.
 

File Name	Description
Contraceptive Tier Exception Request	Used to submit Contraceptive Tier Exception Request for non-covered contraception. Click here for instructions.
Responsible Steps Authorization Form	Provided to members for their providers to complete and submit for prior authorization. Applies to members with Prescription Benefits that require prior authorization or prior coverage.
Prior Authorization Form
Claim Form - Prescription Drug	Used to submit a prescription drug claim directly to Florida Blue.

Find forms required to change your coverage or set up automatic payments.
 

File Name	Description
ACA Change Application - add NewBorn(s), Adopted Children, or Foster Children	For plans with coverage starting January 2014 or later (health care reform plans). This change application is used to request continuous coverage for a new dependent: Newborn(s), Adopted Children or Foster Children. Your next bill will reflect the premium increase. Call your agent with any questions or call 1-800-352-2583.
ACA Change Application - add due to newly married or eligible domestic partner and/or dependents	For plans with coverage starting January 2014 or later (health care reform plans). This change application is used to request continuous coverage for newly married spouse or eligible domestic partner and/or new dependents gained through marriage. Your next bill will reflect the premium increase. Call your agent with any questions or call 1-800-352-2583.
Automatic Payment and Other Payment Options (ACA health and dental and pre-ACA dental plans)	For plans with coverage starting January 2014 or later (health care reform plans). Members can set up automatic payments or make one-time monthly payments by logging in to their member account.
Automatic Payment and Other Payment Options (Pre-ACA health plans)	For plans with coverage that was already in effect before January 2014. Members can set up automatic payments or make one-time monthly payments by logging in to their member account.
Other Insurance Company Information	For plans with coverage that was already in effect before January 2014. This form is used to inform Florida Blue of insurance plans (including Medicare) you have that are supplemental to your Florida Blue plan.
Prior/Concurrent Coverage Affidavit	For plans with coverage that was already in effect before January 2014. This form is used to inform Florida Blue if you currently have or recently had insurance coverage, which your Florida Blue policy will replace.
Change Application - Individual HMO Direct Pay	For plans with coverage that was already in effect before January 2014. This change application is used to update your Underwritten policy (not for health care reform policies) for events like adding a newborn, removing dependants, changing your name or changing your premium payment method. Additional documents may be required.
Change Application - Individual Direct Pay	For plans with coverage that was already in effect before January 2014. This change application is used to update your Underwritten HMO policy (not for health care reform policies) for events like adding a newborn, removing dependents, changing your name or changing your premium payment method. Additional documents may be required.
Continuous Coverage - PPO Eigible Dependent Application	For plans with coverage that was already in effect before January 2014. This application is used to request continuous coverage for a spouse or dependent under Non-HMO plans. Submit this form along with the Underwritten Health Change Application for Direct Pay (Non-HMO).
Continuous Coverage - HMO Eligible Dependent Application	For plans with coverage that was already in effect before January 2014. This application is used to request continuous coverage for a spouse or dependent under HMO plans. Submit this form with the Underwritten Health Change Application for Direct Pay (HMO).
Continuation of Coverage - Qualifying Event	Recently your coverage with your group policy ended. This form will provide you with the documents required to continue your coverage with Florida Blue.

Find forms required to share your health information and establish advanced directives.
 

File Name	Description
Life Planning (Advanced Directives)	Visit the government site to access legal documents that allow you to convey your life planning and care decisions ahead of time. These forms can provide a way for you to communicate your wishes to family, friends and health care professionals, and to avoid confusion later on.

Medicare member forms