Member forms

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

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

Individual and Family Plan applications

Medical Plan Application

Explore your plan options, determine your eligibility for financial help, get a price quote, and apply for a Blue Shield individual or family plan.

Individual and Family Plan Application

Release of Personal Health Information

Authorization for the Use or Disclosure of Health Information

Submit this form to authorize (allow) 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.

English (PDF, 119 KB)
Spanish (PDF, 121 KB)
Vietnamese (PDF, 248 KB)
Chinese (PDF, 347 KB)
Hindi (PDF, 154 KB)
Korean (PDF, 229 KB)

AutoPay

Enroll in AutoPay

Log into your Blue Shield account and set up automatic payments for your checking/savings account or credit card.

Beneficiary

Beneficiary Change Request
Submit this form to add or delete beneficiaries from a term life insurance plan.

Beneficiary Change Request (PDF, 43 KB)

Beneficiary Affidavit
Submit this document when no beneficiary was designated or no designated beneficiary survived the deceased insured.

Beneficiary Affidavit (PDF, 37 KB)

Proof of Death forms

Individual and Family Plans
Beneficiaries should submit this form for proceeds after an insured dies. When submitting the form, include an original certified death certificate.

Individual and Family Plan Statement and Notice of Death (PDF, 468 KB)

Group Plans
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.

Proof of Death (PDF, 117 KB)

Claims

Accelerated Death Benefit Claim

When an insured person becomes terminally ill before age 60, they may get life benefit proceeds prior to death. Before submitting this form, please see plan benefits for specific eligibility.

Accelerated Death Benefit Claim (PDF, 451 KB)

Dismemberment Claim

Submit this form when the insured is making a dismemberment claim in conjunction with their Accidental Death & Dismemberment coverage.

Dismemberment Claim (PDF, 448 KB)

Vision Benefit Claim
Take this form to your appointment to file a claim when getting services from a vision provider that is not in the MESVision provider network.

Vision Benefit Claim (PDF, 73 KB)

Life Insurance Forms

Additional Contact Designation

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.

Life Insurance Additional Contact Designation form (PDF, 443 KB)

Continuity of Care

Continuity of Care Brochure

English brochure (PDF, 1.3 MB)
Spanish brochure (PDF, 1.3 MB)
Vietnamese brochure (PDF, 1.3 MB)
Chinese brochure (PDF, 1.3 MB)
Hindi brochure (PDF, 1.3 MB)
Korean brochure (PDF, 1.3 MB)

Continuity of Care Application

English application (PDF, 96 KB)
Spanish application (PDF, 154 KB)
Vietnamese application (PDF, 222 KB)
Chinese application (PDF, 269 KB)
Hindi application (PDF, 307 KB)
Korean application (PDF, 220 KB)

Language assistance

No cost language service. You can get documents read to you and some sent to you in your language.

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

© California Physicians’ Service DBA Blue Shield of California 1999-2023. Mọi quyền được bảo lưu. California Physicians’ Service DBA Blue Shield of California is an independent member of the Blue Shield Association. Các sản phẩm bảo hiểm sức khoẻ do Blue Shield of California Life & Health Insurance Company cung cấp. Các chương trình chăm sóc sức khoẻ do Blue Shield of California cung cấp.

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