General FormsIBC Forms Online

In the General Forms section you will find “everyday” forms you will need for your Independence Blue Cross business needs.

PDF icon Forms are in pdf format.

Form	Last Updated
Application to Continue Coverage for Handicapped Dependent Child (#01418)	2005-03
Employer Authorization for Access to IBXpress	2011-04
Employer Authorization for Electronic Withdrawal	2007-04
HIPAA Member Authorization Form	2004-11
IBC Davis Vision Claim Form	2007-01
Keystone 65 Group Enrollment/Change Form	2011-02
Keystone Transmittal Form	1997-01
KHPE Dependent Verification Form	2005-01
Personal Choice 65 Group Enrollment/Change Form	2011-02
Personal Choice Out-of-Network Claim Form	2008-10
Point-of-Service Claim Form (#03925)	2008-10
Procedures That Support Safe Prescribing - Fully Insured	2011-09
Procedures That Support Safe Prescribing - Self Insured	2011-09
Select Drug Program Q & A	2008-11
Student Verification Form (#7215)	2005-03
UCCI Large Group Application	2006-07
UCCI Small Group Application	2006-07
Laser Vision Correction	2008-06
Select Drug Program Formulary Benefits	2009-01
Autism Flyer	2009-08
PA Dependent to 30	2009-11
FutureScripts Medical Questionnare - Commercial	2010-11
FutureScripts Prescription Mail Order Form	2011-08
IBC Self Injectable List	2011-08
Infertility Grid	2010-08
Agent of Record Letter	2011-04
Employer Authorization for Access to IBXpress (Consultant)	2011-04
PPO Out-of-Network Claim Form	2009-03
Prior Authorization Flyer - Member	2011-06
Stop-Loss Reporting Form	2011-06
Select Drug Formulary Guide	2011-07
Health Questionnaire Form for Small Group Medical Underwriting	2012-03
Group Formulary (2012)	2011-06
Blue Solutions Renewal Savings Form - Broker	2012-01
Blue Solutions Renewal Savings Form - Rep	2012-01
Request for Continuation of Care	2011-06
FutureScripts Prescription Reimbursement Claim Form	2009-05
Fully Insured Retrospective Funding Arrangements	2012-02