Member forms - Individual and family plans

The forms listed on the menu below are for use by members. These forms are in portable document format (PDF). You may print and copy as needed.

Claim forms

We want to pay your eligible claims as fast as possible, so use these forms to submit claims

• Accident form for dental injury
• International claim form
• Medical claim form

Change Forms

Use these forms to request a change to your current policy, such as name changes, deductible amounts, dependent status and more.

• Metallic change form

Privacy forms

These printable forms allow you to exercise your privacy rights in the most efficient manner. By printing, completing and sending these forms to the Privacy Office, your request will be processed efficiently because we will have the information needed to fulfill the request.

• Authorization for release of information You have the right to authorize Octave Blue Cross and Blue Shield to disclose information regarding claims, payments or other communications to any person or entity.
• Request for accounting You have the right to request a listing of any disclosures we have made of your protected health information for purposes other than payment or healthcare operations.
• Request for confidential communication You have the right to request that we keep communications with you confidential and communicate in an alternate manner
• Request for restrictions You have the right to request that we restrict the use of your protected health information for payment and healthcare operations.
• Request to correct or amend record You have the right to request that any information we created about you be amended if you believe that it is incorrect.
• Request to inspect health information You have the right to inspect or get a copy of records we maintain about you in a designated record set and which we used to make a decision about you.

Other forms

• Continuity of care form
• Designation of authorized appeal representative
• Member appeal submission form
• Other insurance/Coordination of Benefits (COB)Does anyone on your policy have other insurance coverage?
• Request to cancel policy
• Proof of incapacity of a dependent - Physician's form
• Proof of incapacity of a dependent - Policyholder's form