Group Administrator Self-Service

Forms

From time to time, you will need to complete forms in order to administer your health care coverage plan.

The following forms may assist you:

• Agreement for Fully Insured Enrollment Disclosure
  Request Form
• Agreement for Self-Funded Disclosure Request Form
• BlueCare Group Enrollment Application Change Form
  (03-B0044)
• BlueCare Major Medical Claim Statement Form
• BlueCare Traditional Claim Statement Form (FPLIC)
• Disabled Dependent Application
• Highmark Claim Form (1500A)
• HIPAA Authorization Form (1.1a)
• Mail Order Prescription Drug Order Form (03-B053B)
• Medicare Secondary Payer Reply Form (04-B0010)
• Prescription Drug Reimbursement Form (1-12-06)
• Supplemental Information For Dependent Enrollment (04-F124B)
• Understanding Your Explanation of Benefits (EOB)