Member Forms

You can download the online forms in pdf format by clicking on the headlines below.

• Self-referred Care Claim Form (POS)
• Out-of-network Claim Form (PPO)
• Prescription Reimbursement Claim Form
• Prescription Mail Service Order Form
• Davis Vision Out-of-network Claim Form
• HIPAA Authorization Form
• Influenza Vaccination Reimbursement Form
• Application to Continue Coverage for a Disabled Dependent Child
  Disabled dependents may be eligible to continue on the policy if proof of eligibility is met. To apply for overage disabled dependent coverage, complete and return the form above to:
  
  Independence Blue Cross
  1901 Market Street
  Philadelphia, PA 19103

Dependents may be eligible for coverage until they reach age 26. Contact your benefits representative for information on how to enroll your student dependent.