get adobe readerSome documents on this page may require the Adobe Reader.
You may download the Adobe Reader here.

Medical Forms

Enrollment Forms:

Medical Benefits (Non-Medicare) Enrollment

Medicare Supplement Plan Application

Statement of Health Form

Application for Medical Benefits for Adult Children (Under Age 26)

Medical Claim Form:

To obtain a member submitted claim form or international claim form, please visit the Highmark website at www.highmarkbcbs.com or contact customer service at 866.763.9471 for assistance.

Pharmacy Claim Form:

To obtain a pharmacy reimbursement form, please login to your account at www.express-scripts.com or contact customer service at 800.939.3781 for assistance.

Other Health Plan Related Forms:

Domestic Partnership Statement of Financial Interdependence Form

Certification of Domestic Partner as Dependent or Non-Dependent

Protected Health Information Release Form