Member forms - Individual and family plans

The forms listed on the menu below are for use by members. These forms are in portable document format (PDF). You may print and copy as needed.

Note: Some employers use customized forms or electronic systems. Please check with your Human Resources office.

Member bank draft forms

If you have individual coverage and a monthly premium, you can pay it through a pre-authorized bank draft. To get started, choose a bank draft form below based on your plan type.

• Individual members with metallic plans (Gold, Silver, Bronze, Catastrophic) [pdf]
  You can email your form to [email protected] or mail it to Arkansas Blue Cross and Blue Shield, EES Membership Financial, P.O. Box 34320, Little Rock, AR 72203-4320. You can also fax it to the number listed on the form
• Individual members with Metallic plans (Gold, Silver, Bronze, Catastrophic) — Spanish version [pdf] 
  Puede enviar su formulario por correo electrónico a [email protected] o enviarlo por correo a Arkansas Blue Cross y Blue Shield, EES Membership Financial, P.O. Box 34320, Little Rock, AR 72203-4320. También puede enviarlo por fax al número que figura en el formulario.

Important

If you receive a paper bill after you submit your bank draft form, then we are still processing your auto-draft request. You will need to use one of the other payment options to pay your bill. Your bank draft should be effective the following billing period once your auto-draft form is processed. If you have any questions, please call the phone number listed on your bill or the back of your Member ID card.

Change forms

Use these forms to request a change to your current policy, such as name changes, deductible amounts, dependent status and more.

• Metallic change form [pdf]
  Use this form for all metallic medical plans (Gold, Silver, Bronze or Catastrophic)
• Newborn and adopted child change form [pdf]

Claim forms

We want to pay your eligible claims as fast as possible, so use these forms to submit claims.

• Accident form for dental injury [pdf]
• BlueCard subscriber's claim form [pdf]
  
• International claim form [pdf]
• Medical claim form [pdf]
• Prescription claim form [pdf]

Privacy forms

These printable forms allow you to exercise your privacy rights in the most efficient manner. By printing, completing and sending these forms to the Privacy Office, your request will be processed efficiently because we will have the information needed to fulfill the request.

• Authorization for release form [pdf]
  You have the right to authorize Health Advantage to disclose information regarding claims, payments or other communications to any person or entity.
• HIPAA PHI disclosure form for under age 65 products [pdf]
• Request for accounting [pdf]
  You have the right to request a listing of any disclosures we have made of your protected health information for purposes other than payment or healthcare operations.
• Request for confidential communication [pdf] You have the right to request that we keep communications with you confidential and communicate in an alternate manner
• Request for restrictions [pdf]
  You have the right to request that we restrict the use of your protected health information for payment and healthcare operations.
• Request to correct or amend record [pdf]
  You have the right to request that any information we created about you be amended if you believe that it is incorrect.
• Request to inspect health information [pdf]
  You have the right to inspect or get a copy of records we maintain about you in a designated record set and which we used to make a decision about you.

Other forms

• Continuity of care form
• Designation of authorized appeal representative [pdf]
• Member appeal submission form [pdf]
• Other insurance/Coordination of Benefits (COB) [pdf]
  Does anyone on your policy have other insurance coverage?
• Prescription mail service order form [pdf]
  If your policy has a mail-order drug benefit, use this form to order new and/or refill mail service prescriptions
• Request to cancel policy [pdf]
• Proof of incapacity of a dependent - Physician's form [pdf]
• Proof of incapacity of a dependent - Policyholder's form [pdf]