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Health Plans — Miscellaneous

• Dental Claim Form
• Medex Subscriber Claim Form
• Subscriber Claim Form

Health and Wellness

• Fitness Benefit Form
• Weight Loss Benefit Form

Pharmacy

• Patient Profile Form for Mail Service Pharmacy
  Express Scripts^®', Inc. patient information form. You must download, print, fill out this form, and submit along with your prescription to Express Scripts.
• Drug Claim Form for Mail Service Pharmacy
  Express Scripts, Inc. drug order form. You must download, print, fill out this form, and submit along with your original prescription receipts to Express Scripts.
• Physician Request for Prior Authorization Form
  This is also referred to as the Formulary Exception form. Your doctor may choose to submit this form if he/she feels that a drug from the Prior Authorization list is right for you.

Administrative

• Member's Authorization for Release of Information
  A form authorizing Blue Cross Blue Shield of Massachusetts to disclose claims and medical information to a named third-party.
• Member's Designation of a Personal Representative
  A form naming an individual as your personal representative, who may act on your behalf in regard to health care coverage provided through Blue Cross Blue Shield of Massachusetts.
• Retaining Coverage for Disabled Dependent Child
• Student Certificate Affidavit
  A form that certifies that your child is a full-time student at an accredited school. This allows them to continue to be eligible for health coverage under your policy.
• Student Medical Leave Affidavit form
  This form certifies that your student dependent is on a medically necessary leave of absence from a post-secondary school.
• Direct-Pay Application for a Membership Change

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.
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