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Request for Continuity of Care Service for established members and new enrollees. English*
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Chinese
Vietnamese
Hindi
Korean
Continuity of Care Notice
Important notice for new HMO enrollees
English
Spanish
Chinese 
Vietnamese
Continuity of Care Flyer English
Spanish
Chinese 
Vietnamese

Hindi
Korean
Authorization for the Use or Disclosure of Health Information English
Spanish
Chinese
Vietnamese
Hindi
Korean
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Subscriber's Statement of Claim Download 
American Specialty Health (ASH) – Subscriber Claim Form Download
Authorization for Release of Personal and Health Information Download
Pharmacy Reimbursement Download
Beneficiary Change Request Download
Blue Shield Global Core International Claim Download 
Proof of Death Form: Group Life Download
Accelerated Death Benefit Claim Form: Group Life Download
Dismemberment Claim Form: Group Life Download
Dental Claim Download
Vision Claim Download
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Continuation of Coverage Application (COBRA and Cal-COBRA)
For existing groups requesting effective dates of October 1, 2020, and later, this form replaces the "COBRA Continuation of Coverage Application”, the “Cal-COBRA Election”, the "Cal-COBRA Dental Election", and the “Continuing Group Coverage After Federal COBRA” forms. Use this form to apply for a continuation of coverage (federal COBRA or Cal-COBRA).

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Employer Notification of Qualifying Events under Cal-COBRA
This form replaces the “Employer Notification of Qualifying Events under Cal-COBRA (ENF)” form for groups requesting changes effective October 1, 2020, and later. Complete this form each time a covered employee has a qualifying event that causes them to be eligible for continuation coverage under the California Continuation Benefits Replacement Act (Cal-COBRA).

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Cal-COBRA Take-Over
New groups should use this form when changing carriers to Blue Shield for Cal-COBRA members covered under a previous carrier. Employers are responsible for notifying their Cal-COBRA members of the transition to a new carrier and Cal-COBRA members are required fill out the form and submit to the Cal-COBRA team within 30 days of transition.

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