Member Forms

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

• Out-of-Network Claim Form
• Disabled Dependent Application

Process for completing a Disabled Dependent Application:
When a covered dependent is terminated based on aging off at 26 years old, they can retain coverage through the disabled covered dependent enrollment process.

To apply for disabled dependent coverage, complete the application with the covered dependent’s provider and return the form electronically to IBCMembershipDisabilityApplication@ibx.com or mail copies of the form to:

Independence Blue Cross
c/o Enrollment Services
1901 Market Street
Philadelphia, PA 19103

It can take 5–7 business days to review a submitted application. However, depending on the circumstances, a review can take more time. Once reviewed, the application decision will be mailed back with one of the following statuses:

• Approved for either:
  • One-year or short-term enrollment — This will require annual recertification. The subscriber will receive notice 60 days before the covered dependent’s termination.
  • Permanent lifetime enrollment — Annual recertification is not required
• Request for more information: In some cases, the Medical Review team will reach out to the provider and attempt to obtain more information.
• Denied along with the reason why