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Medical/Vision/Dental Claims & Reimbursement Forms
Find forms for reimbursement of medical vision or dental expenses and other related forms. Medicare forms are located below.
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HMO Grievance & Appeal Form
Used to appeal a coverage decision and request formal written review of how a claim was processed. -
Health Plan Grievance & Appeal Form (Non-HMO)
Used to appeal a coverage decision and request formal written review of how a claim was processed. -
Member Appeals Appointment of Representative (AOR) Form
Used by members to appoint someone to represent them in connection with a specific claim. Once completed, contact Member Services for Submission Instructions. -
External Review Request Form
Used by Members to file an External Review request after exhausting their Internal Appeals Process. -
Medical Claim
Used to submit a claim directly to Florida Blue. -
International Medical Claim
Used to submit a claim for international medical services directly to Florida Blue. -
BlueVision Claim Form
Used to submit a claim for vision services received from an out-of-network provider. -
Accident Letter
Used to furnish Florida Blue or Health Options information if you have recently experienced a claim related to an accident. -
Coverage Protocol Exemption Request Form
Used to submit Protocol Exemption Request for Step-Therapy protocol, click here for instructions. -
Dental Claim Form
Find claim forms and brochures for dental services covered by your BlueDental plan.
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HMO Grievance & Appeal Form
Used to appeal a coverage decision and request formal written review of how a claim was processed. -
Health Plan Grievance & Appeal Form (Non-HMO)
Used to appeal a coverage decision and request formal written review of how a claim was processed. -
Member Appeals Appointment of Representative (AOR) Form
Used by members to appoint someone to represent them in connection with a specific claim. Once completed, contact Member Services for Submission Instructions. -
External Review Request Form
Used by Members to file an External Review request after exhausting their Internal Appeals Process. -
Medical Claim
Used to submit a claim directly to Florida Blue. -
International Medical Claim
Used to submit a claim for international medical services directly to Florida Blue. -
BlueVision Claim Form
Used to submit a claim for vision services received from an out-of-network provider. -
Accident Letter
Used to furnish Florida Blue or Health Options information if you have recently experienced a claim related to an accident. -
Coverage Protocol Exemption Request Form
Used to submit Protocol Exemption Request for Step-Therapy protocol, click here for instructions. -
Dental Claim Form
Find claim forms and brochures for dental services covered by your BlueDental plan.
Prescription Drug Forms
Find forms for reimbursement of prescription expenses, mail order drugs and authorization requests.
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Coverage Exception Request for Individual Exchange Plan Members
Used to submit coverage exception request for drugs not covered and only applies to Individual Exchange members -
Contraceptive Tier Exception Request form
Used to submit Contraceptive Tier Exception Request for non-covered contraception. Click here for instructions. -
HIV PrEP Tier Exception Form
Provided to members for their providers to complete and submit for review. Applies to Commercial plans with USPSTF preventive care pharmacy benefit. -
Responsible Quantity Limit 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. -
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
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. -
Prescription Drug Claim
Used to submit a prescription drug claim directly to Florida Blue.
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Coverage Exception Request for Individual Exchange Plan Members
Used to submit coverage exception request for drugs not covered and only applies to Individual Exchange members -
Contraceptive Tier Exception Request form
Used to submit Contraceptive Tier Exception Request for non-covered contraception. Click here for instructions. -
HIV PrEP Tier Exception Form
Provided to members for their providers to complete and submit for review. Applies to Commercial plans with USPSTF preventive care pharmacy benefit. -
Responsible Quantity Limit 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. -
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
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. -
Prescription Drug Claim
Used to submit a prescription drug claim directly to Florida Blue.
Coverage and Premium Payment Forms
Find forms required to change your coverage or set up automatic payments.
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Adding an eligible new dependent to your health plan
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. -
Adding a new spouse or eligible domestic partner and/or dependents to your health plan
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 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 Information
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. -
Underwritten Health Change Application for Direct Pay, Individual Under-Age 65 Members (HMO)
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. -
Underwritten Health Change Application for Direct Pay, Individual Under-Age 65 Members (Non-HMO)
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. -
Eligible Dependent Application (Non-HMO)
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). -
Eligible Dependent Application (HMO)
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). -
Automatic Payment Option (Medicare Supplements)
This form is used to authorize monthly premium payments for Medicare Supplement plans directly from your bank account. The plan name must start with “Medicare” (not “BlueMedicare”) to use this form. Check the plan name on your member ID card to be sure. -
Automatic Payment Option (BlueMedicare)
This form is used to authorize monthly premium payments for BlueMedicare Supplement plans directly from your bank account. The plan name must start with "BlueMedicare" (not just "Medicare") to use this form. Check the plan name on your member ID card to be sure. -
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.
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Adding an eligible new dependent to your health plan
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. -
Adding a new spouse or eligible domestic partner and/or dependents to your health plan
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 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 Information
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. -
Underwritten Health Change Application for Direct Pay, Individual Under-Age 65 Members (HMO)
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. -
Underwritten Health Change Application for Direct Pay, Individual Under-Age 65 Members (Non-HMO)
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. -
Eligible Dependent Application (Non-HMO)
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). -
Eligible Dependent Application (HMO)
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). -
Automatic Payment Option (Medicare Supplements)
This form is used to authorize monthly premium payments for Medicare Supplement plans directly from your bank account. The plan name must start with “Medicare” (not “BlueMedicare”) to use this form. Check the plan name on your member ID card to be sure. -
Automatic Payment Option (BlueMedicare)
This form is used to authorize monthly premium payments for BlueMedicare Supplement plans directly from your bank account. The plan name must start with "BlueMedicare" (not just "Medicare") to use this form. Check the plan name on your member ID card to be sure. -
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.
Personal Information Forms
Find forms required to share your health information and establish advanced directives.
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Life Planning (Advanced Directives)
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. -
Coordination of Benefits Questionnaire
Used to determine the order of how plans pay their claims when a member has more than one health benefit plan.
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Life Planning (Advanced Directives)
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. -
Coordination of Benefits Questionnaire
Used to determine the order of how plans pay their claims when a member has more than one health benefit plan.
FB MEM FRM 001 NF 042022