Blue Cross Claim Form - Use this form to file medical claims for charges you incurred when using an out-of-network provider.
Blue Cross Prior Concurrent Affidavit Form - 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.
Blue Cross Out of the Country Form - Use this 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.
Employee Change of Information Form for Blue Cross Medical and Delta Dental - Use the form to change your address, add or delete yourself and/or your dependents, or name change. You must provide proof of why the change is needed for all except address changed. 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.
