Forms

• ADA Dental Claim Form

• Claim Form Instruction Booklet

• Medical Claim

• Dental Claim

• Pharmacy Claim

• Pharmacy Compounded Medication Claim

• Autopay Authorization

• Medicare Supplement Application

• Attestation Form

• MHPAEA Form Updates Revisions

• Medicare Supplement Outline of Coverage

• Medicare Supplement Rate Info

• Medicare Supplement Application

• Medigap Policy

• BCBSAZ Confidential Information Release

• BCBSAZ Confidential Information Release in Spanish

• BCBSAZ Confidential Information Release for HIV Related Information

• Accounting_Request_Form_2022_fillable

• Amendment_Request_2022_fillable

• Authorized Representative Designation

• Confidential_Communications_Form_2022_fillable

• PHI_Access_Request_Form_2016_wDisclosures_fillable

• Privacy_Complaint_Form_2016_fillable

• Restriction_Request_Form_2022_fillable

• BCBSAZ Confidential Information Release for HIV Related in Spanish

• HIPAA Notice of Privacy Practices