You can download the online forms in pdf format by clicking on the headlines below.
- Global Core International Claim Form
- Out-of-Network Claim Form
- Seasonal Influenza 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 disabled dependent coverage, complete and return the form above to:
Independence Blue Cross
Attn: Teleflex Account Team
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 dependent.