Formularios

Puede descargar e imprimir formularios o puede solicitar formularios para recibirlos por correo.

Formularios para descargar

Formulario de reclamaciones médicas

Formularios de reclamaciones de farmacia

Formularios de reclamaciones dentales y de la vista

Formularios de reclamaciones internacionales

To submit a claim online, visit Blue Cross Blue Shield Global Core®, or print out the form below.

NOTA: los formularios de reclamaciones internacionales deben enviarse a:

Service Center

P.O. Box 2048
Southeastern, PA 19399


Formularios de apelaciones

Solicitud de Check It Out®

Formularios de la cuenta de gastos flexibles (FSA)

HIPAA

Fraude

Claim forms are for claims processed by Capital Blue Cross within our 21-county service area in Central Pennsylvania and Lehigh Valley. If you receive services outside Capital Blue Cross' 21-county area, another Blue Plan may have an agreement to process your claims, even though your coverage is with Capital Blue Cross. You should obtain claim forms from the local Blue Plan that processes your claims. The Capital Blue Cross service area includes these counties: Adams, Berks, Centre County, Columbia, Cumberland, Dauphin, Franklin, Fulton, Juniata, Lancaster, Lebanon, Lehigh, Mifflin, Montour, Northampton, Northumberland, Perry, Schuylkill, Snyder, Union and York.