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Downloadable Forms |
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The
Authorization to Share "Protected Health Information" form
(PDF) is used to authorize Blue Cross and Blue Shield of Florida
to share personal health information to persons you designate,
such as a spouse or adult child. |
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Use
the
out of country Blue Cross claim form to file a medical claim
for charges you incurred outside the United States. All medical
bills must be written in English and charges in U.S. dollars.
Submit the claim to the address provided on the claim form. |
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Use the
Blue Cross claim form to file
medical claims for charges you incurred when using an
out-of-network provider. |
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For the FCL Dental Claim form – Use
the
Florida Combined Life Dental Claim Form |
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For the
Blue Cross Prior Concurrent Affidavit – this form must be
completed when you or your dependents are late entrants into the
plan. In other words, if you do not apply for coverage on
yourself and/or your eligible dependents during your initial
eligibility period. |
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Pension Plan Designation of Beneficiary – you completed this
form during your first thirty days of employment and named a
pension plan benefit beneficiary. Use this form if there is a
need to change your beneficiary.
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Prudential Life Disability Enrollment Beneficiary form - you
completed this form during your first thirty days of employment
and named a basic term life plan beneficiary. Use this form if
there is a need to change your beneficiary.
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Employee Change of Information Form - Blue Cross Medical and FCL
Dental – Use this form to
change your address, add or delete yourself and/or your
dependents, name change. You must provide proof of why the
change is needed for all except address change. For example, if
you change your name, you must provide a copy of your new social
security card; if you add a dependent because your spouse
changes employment, you must submit a document that reflects
that the other coverage has been cancelled. All forms must be
submitted to the Diocese Benefits Office within 30 days of the
date of the event causing the change. |
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Blue Cross Appeal Letter – if Blue Cross denies your claim,
you can complete this form to appeal their decision. |
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Blue Cross Dependent Verification Form – Once a year, Blue
Cross sends this form to all participants who are covering a
child older than age 19. You must complete the form and return
it to Blue Cross by the deadline date or Blue Cross will assume
that the child is no longer eligible for coverage and terminate
coverage on that child.
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RxEDO Mail Order Prescription
Brochure |
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RxEDO Mail Order Prescription
Form |
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RxEDO Prescription Claim Form |
