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Medical Forms

Enrollment Forms:

Medical (Non-Medicare) and Dental Benefits Enrollment

Medicare Advantage Plan and Dental Benefits Enrollment Form

Medical and Dental Benefits Annual Change Form

Continuation of Coverage Form

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