Forms & Documents
- Medical Claim FormOpen a PDF
- Dental Claim FormOpen a PDF
- Prescription Drug Claim FormOpen a PDF
- BlueHealthy Dollars Reimbursement FormOpen a PDF
- BlueHealthy Choices Lifestyle Benefits Reimbursement FormOpen a PDF
- SimplyBlue Gym Membership Incentive Reimbursement FormOpen a PDF
- Flexible Spending Account or Medical Reimbursement Account Forms
- Adoption or Foster Dependent FormOpen a PDF
- Adult Disabled Dependent FormOpen a PDF
- ARPA COBRA Subsidy Attestation FormOpen a PDF
- Away From Home Care Guest Membership ApplicationOpen a PDF
- Continuing Coverage for Students on Medical Leave FormOpen a PDF
- Dependent Certification (Student Verification) FormOpen a PDF
- Domestic Partner Affidavit FormOpen a PDF
- Medicare Eligibility Form for Commercial PlansOpen a PDF
- Qualified Medical Child Support Order Certification FormOpen a PDF
- Qualified Medical Child Support Order Disenrollment FormOpen a PDF
- Young Adult Option Certification (Dependent Age 29) FormOpen a PDF
Medical and dental enrollment forms (101+ full-time equivalent employees)
Forms for small groups (100 or fewer), individuals, and families are available in Blue on Demand
- Choose application based on whether the product requires a primary care physician
- Select the plans your group offers from the dropdown(s) under Medical and Dental Plan Selection
- PPO/EPO/Indemnity - No Primary Care Physician (PCP)Open a PDF
- POS/HMO - Requires Primary Care Physician (PCP)Open a PDF
Additional enrollment forms
- Additional Dependent AddendumOpen a PDF
- Membership Cancellation WorksheetOpen a PDF
- Vision Enrollment FormOpen a PDF
Medicare enrollment forms
- Medicare Supplement Enrollment FormOpen a PDF
- Excellus BCBS HMO / PPO / Medicare Supplement Disenrollment
- Enroll, change or cancel coverage for a Medicare Advantage or Medicare Supplemental member
2026 enrollment applications
Medical sales tools and resources
At-a-glance products and benefits*
- Updated materials are coming soon!
Member brochures
Dental sales tools and resources
- Annual Maximum Rollover
- Dental Blue Options
- SimplyBlue Plus Dental
- How Pediatric Dental Benefits Work
Dental at-a-glance charts
- Rochester region
- Syracuse region
- Albany, Mid-Hudson, Utica region
Vision sales tools and resources
- Simply Vision Plans
- Employer Simply Vision Plan Flyer
- Member Simply Vision Plan Flyer
- Davis Vision Discount Flyer
- Davis Vision Provider List
- Safety Eyeglass Program Flyer
Wellbeing tools and resources
ThriveWell
- ThriveWell Member Guide
- ThriveWell Quick Start Guide
- ThriveWell Member Program Flyer
- Rewards Points and Cash Flyer
- Rewards Flyer
- Foodsmart Flyer
* Rates shown are subject to approval by the New York State Department of Financial Services (NYS DFS)
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