Claims Forms

Medical Plans | Dental and Vision Plans | Life Insurance Plans

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Medical Plans

Form Purpose Download

Subscriber’s Statement of Claim
(CLM14850)

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, 451KB)
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, 68KB)

Subscriber’s Statement of Claim for Blue Shield Life
(CLM-15481)

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, 75KB)

International Claim Form
(C14764)

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, 61KB)

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, 138KB)
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
(PDF, 48KB)
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, 36.5KB)


Dental and Vision Plans

Form Purpose Download
Dental Service Report - Claim Form
(C11716)
  Dental Service Report - Claim Form
(PDF, 89KB)
Vision Benefit Claim Form
(C4669)
  Vision Benefit Claim Form
(PDF, 73KB)


Life Insurance Plans

Form Purpose Download
Life Insurance Proof of Death
(ABU1180)
  Life Insurance Proof of Death
(PDF, 89KB)
Life Insurance Waiver of Premium Request
(ABU1182)
  Life Insurance Waiver of Premium Request
(PDF, 580KB)
Accelerated Death Benefit Claim
(ABU1139)
  Accelerated Death Benefit Claim
(PDF, 451KB)
Dismemberment Claim
(ABU1181)
  Dismemberment Claim
(PDF, 593KB)
Beneficiary Affidavit
(CPC1018)
To be completed when no beneficiary was designated, or no designated beneficiary survived the insured deceased. Beneficiary Affidavit
(PDF, 455KB)