Claims

Claims

Claims

Form

 

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Subscriber's Statement of Claim

 

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American Specialty Health (ASH) – Subscriber Claim Form

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Authorization for Release of Personal and Health Information

 

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Prescription Drug Reimbursement Form

 

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Blue Shield Global Core International Claim

 

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Proof of Death Form: Group Life

 

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Accelerated Death Benefit Claim Form: Group Life

 

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Dismemberment Claim Form: Group Life

 

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Dental Claim

 

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Vision Claim

 

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Waiver of Premium Claim Form: Group Life
If a member becomes totally disabled, the life premium may be waived.

 

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Beneficiary Affidavit & Assignment Form

 

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Beneficiary Change Request

 

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