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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

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

Protected Health Information Release Form