If you need assistance completing any forms or have any questions, please call customer service at 1-866-798-0803. Representatives are available Monday through Friday, 8:30 a.m. to 8:00 p.m. Eastern Time. A translation line is available for most languages.
Authorized Representative Form / Formulario de Representante Autorizado
Medical Claim Form (Indemnity) / Formulario de Reclamo de Gastos Médicos (Indemnity)
Medical Claim Form (MEC/MVP) / Formulario de Reclamo de Gastos Médicos (MEC/MVP)
Prescription Drug Claim Form (Use this form if RxGRP: DISCOUNT is on your ID card.) / Formulario de Reclamo de Recetas Médicas (Utilice este formulario si RxGRP: DISCOUNT está en su tarjeta de identificación.)
Prescription Drug Claim Form (Use this form if RxGRP: BXPAI is on your ID card.)
Prescription Drug Reimbursement Claim Form (MEC)
Accidental Loss of Limb or Sight Claim Form
Accidental Loss of Limb or Sight Claim Form-Attending Physician Statement
Dental Claim Form
EyeMed Out-of-Network Claim Form
Missed Premium Direct Payment Form / Formulario Para el Pago Directo de Primas no Cubiertas
Term Life or Accidental Death Claim Form
HIPAA-all groups