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Member Forms

There are forms available for downloading, please scroll down to see them all.

Click the name of the form to start the download. You must have Acrobat Reader to use these PDF forms. 

  • Individual and Family Plan Application
    Explore your plan options, determine your eligibility for financial assistance, get a quote, and apply for a Blue Shield individual or family plan.

  • Individual and Family Plan Dental Application (PDF, 197KB)
    Current or prospective members should use this application to apply for dental and vision coverage.

  • Release of Personal Health Information
    English (PDF, 1.6MB)
    Spanish (PDF, 1.6MB)
    Vietnamese (PDF, 1.7MB)
    Chinese (PDF, 1.9MB)
    Hindi (PDF, 1.6MB) 
    Submit this form to authorize Blue Shield to release your personal and health information according to your instructions. To protect your privacy, Blue Shield requires authorization to release your information. 

  • EZ Pay Form
    In order to make changes to your monthly premium, log into your Blue Shield account and access the Payment Center tab. You may also call Customer Service at 888-256-3650. 

  • Beneficiary Change Request (PDF, 455KB)
    Submit this form to add or delete beneficiaries from a term life insurance plan.

  • Beneficiary Affidavit (PDF, 455KB)
    Submit this document when no beneficiary was designated or no designated beneficiary survived the deceased insured.

  • Individual and Family Plan Proof of Death (PDF, 468KB)
    Beneficiaries should submit this form for proceeds after an insured dies. When submitting the form, include an original certified death certificate.

  • Proof of Death (PDF, 454KB)
    Group Administrators should submit this form after an employee with Life Insurance dies. When submitting the form, include an original certified death certificate, proof of beneficiary designation, and proof of eligibility. 

  • Accelerated Death Benefit Claim (PDF, 451KB)
    When an insured person becomes terminally ill before age 60, they may receive life benefit proceeds prior to death. Before submitting this form, please see plan benefits for specific eligibility.

  • Dismemberment Claim (PDF, 448KB)
    Submit this form when the insured is making a dismemberment claim in conjunction with their Accidental Death & Dismemberment coverage.  

  • Vision Benefit Claim (PDF, 73KB)
    Take this form to your appointment to file a claim when obtaining services from a vision provider that is not in the MESVision provider network.

  • Life Insurance Additional Contact Designation form (PDF, 1MB)
    For Individual and Family Plan Subscribers: Complete this form to add an additional contact person(s) to receive a notice of lapse or termination of your life insurance policy if your premium is not paid. 

     
  • Continuity of Care Brochure
    English brochure (PDF, 1.6MB)
    Spanish brochure (PDF, 1.6MB)
    Vietnamese brochure (PDF, 1.8MB)
    Chinese brochure (PDF, 2.0MB)
    Hindi brochure (PDF, 1.7MB)

  • Continuity of Care Application
    English application (PDF, 1.7MB)
    Spanish application (PDF, 2.7MB)
    Vietnamese application (PDF, 1.9MB)
    Chinese application (PDF, 2.0MB)
    Hindi application (PDF, 1.7MB)

Log in to your Blue Shield Account to access additional forms available in the member account area.

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