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Medical Forms

Enrollment Forms:

Medical Benefits (Non-Medicare) Enrollment

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 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 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