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- Debit Authorization Recurring Payment Authorization Form. Schedule your payment to be automatically deducted from your bank account.
- Deceased Member Affidavit
A form used for claim reimbursement by the surviving spouse or next of kin of a deceased subscriber.
- Direct Pay Application for a Membership Change Pay
A form to make changes to Direct Pay after a membership change due to circumstances such as marriage, divorce, birth of a child, or loss of eligibility.
- Documentation of Legal Representative Status for Member A form documenting the legal authority of an individual to act on a member’s behalf in making decisions about the member’s health care.
- Member’s Request for an Accounting of Disclosures A form to request accounting of certain disclosures of your protected health information.
- Member’s Designation of an Authorized Representative A form designating an individual as your authorized representative, who may discuss and receive information in regards to your health care coverage provided through Blue Cross Blue Shield of Massachusetts.
- Member’s Request to Amend Protected Health Information A form to request an amendment to Protected Health Information (PHI) that Blue Cross Blue Shield of Massachusetts maintains in a designated record set.
- Our Commitment to Confidentiality
A brochure outlining how your medical information may be used and disclosed and how you can get access to this information.
- Permission for One-Time Disclosure of Information
A form authorizing Blue Cross Blue Shield of Massachusetts to send specific information to a specific individual
- Renewal Audit Package
You and your dependents must live in Massachusetts to renew your individual health plan with Blue Cross Blue Shield of MA. Use this form to show your eligibility.
- Retaining Coverage for Disabled Dependent Child
- Student Certificate Affidavit
A form that certifies that your child is a full-time student at an accredited school. This allows them to continue to be eligible for health coverage under your policy.
- Student Medical Leave Affidavit Form
This form certifies that your student dependent is on a medically necessary leave of absence from a post-secondary school.
- Transgender Services
A form detailing how to request prior authorization, or pre-approval, before gender affirming (transgender) services.