Form | Download |
---|---|
Request for Continuity of Care | English Spanish 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 |
Form | Download |
---|---|
Subscriber's Statement of Claim | Download |
American Specialty Health (ASH) – Subscriber Claim Form | Download |
Out of State 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 |
Form | Download |
---|---|
Continuation of Coverage Application (COBRA and Cal-COBRA) |
Download (Fillable PDF) |
Employer Notification of Qualifying Events under Cal-COBRA |
Download (Fillable PDF) |
Cal-COBRA Take-Over |
Download (Fillable PDF) |
Cal-COBRA Election Form This form is for members to enroll in Cal-COBRA is they have exhausted their Federal Cal-COBRA coverage, are not eligible for Federal Cal-COBRA coverage due to their employer's type of coverage, or are moving from another carrier's Cal-COBRA policy to a Cal-COBRA policy under Blue Shield. |
Download |
Form |
DOI |
English |
Spanish |
DMHC |
English |
Spanish |
Other Languages |
Chinese |
Hindi |
Vietnamese |
Korean |