Claims Forms
Medical Plans | Dental and Vision Plans | Life Insurance Plans
Get additional forms:
Enrollment | Additions, Changes and Deletions
| Form | Purpose | Download |
|---|---|---|
|
Subscriber’s Statement of Claim |
Employees should use this form ONLY when the provider of service does not submit their claim directly to Blue Shield. This is for Blue Shield of California plans. |
Subscriber's Statement of Claim (PDF, 103 KB) |
| Subscriber Claim Form for Services Received Outside California (CLM14850-BC) | Employees should use this form ONLY when the provider of service does not submit their claim directly. This form is used for medical services received outside of California. This is for Blue Shield of California plans. | Subscriber Claim Form for Services Received Outside California (PDF, 99 KB) |
|
Subscriber’s Statement of Claim for Blue Shield Life |
Employees should use this form ONLY when the provider of service does not submit their claim directly to Blue Shield. This is for Blue Shield Life plans. |
Statement of Claim – Blue Shield Life (PDF, 95 KB) |
|
International Claim Form |
Employees should only use this form if they paid out of pocket for covered services while out of the country. If the provider directly billed Blue Shield, employees should use the Blue Shield Global Core International Claim Form below. |
International Claim Form (PDF, 114 KB) |
|
Blue Shield Global Core International Claim Form |
Employees use this form if the out-of-country provider directly billed Blue Shield of California for covered services. |
Blue Shield Global Core International Claim Form (PDF, 138 KB) |
| Blue Shield of California Prescription Drug Benefit – Direct Reimbursement Claim | Employees who are part of PPO plans that have the Blue Shield Rx Program can use this direct reimbursement form when they have used a non-network pharmacy, or when they did not present their ID card at a network pharmacy during the first 30 days of eligibility. | Prescription Drug Benefit Direct Reimbursement Claim Form English (PDF, 278 KB) Spanish (PDF, 1.3 MB) |
| Prescription Drug Program for Mail Service Prescriptions | Employees who have the Blue Shield Prescription Mail Service benefit can contact the mail service pharmacy at (866) 346-7200 or visit caremark.com. | Prescription Drug Program for Mail Service Prescriptions Form (PDF, 36.5 KB) |
| Form | Purpose | Download |
|---|---|---|
| Dental Service Report – Claim Form (C11716) |
Dental Service Report – Claim Form (PDF, 168 KB) |
|
| Vision Benefit Claim Form (C4669) |
Vision Benefit Claim Form (PDF, 265 KB) |
| Form | Purpose | Download |
|---|---|---|
| Life Insurance Proof of Death (ABU1180) |
Life Insurance Proof of Death (PDF, 140 KB) |
|
| Life Insurance Waiver of Premium Request (ABU1182) |
Life Insurance Waiver of Premium Request (PDF, 550 KB) |
|
| Accelerated Death Benefit Claim (ABU1139) |
Accelerated Death Benefit Claim (PDF, 108 KB) |
|
| Dismemberment Claim (ABU1181) |
Dismemberment Claim (PDF, 555 KB) |
|
| Beneficiary Affidavit (CPC1018) |
To be completed when no beneficiary was designated, or no designated beneficiary survived the insured deceased. | Beneficiary Affidavit (PDF, 119 KB) |