Claim Forms

Claim Forms

Form Download
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

Contact Us

  • Producer Services (800) 559-5905

    Employer Services (800) 325-5166

  • Blue Shield of California

    PO Box 272540

    Chico, CA 95927-2540

© California Physicians’ Service DBA Blue Shield of California 1999-2022. All rights reserved. California Physicians’ Service DBA Blue Shield of California is an independent member of the Blue Shield Association.

Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.