All forms must be signed, then either faxed or mailed.
FEPblue.org - A one-stop source for FEP claim forms.
Incident/accident questionnaire - Submit this form if you or a covered dependent has an injury or if a claim is pending for this information.
Other health insurance questionnaire - Complete this form to provide further information regarding other health insurance coverage. If this form is not completed
and returned, claims may be delayed or denied.
Medicare certification form - Submit this form to clarify information about Medicare coverage status.
Healthcare information release request - Use this form in the event you choose to allow another individual (usually a spouse or child) access to your federally
protected health information and records.
Authorization for release of psychotherapy notes - Use this form to authorize us to release your psychotherapy notes (that we maintain) to a specific
person or entity.
Healthcare information non-disclosure request - Use this form to tell us not to share your personal information with certain individuals.
Member appeal submission form - This form is for member use only and can be used to follow the Federal Employees Health Benefits Program disputed claims process
to dispute our decision on a post-service claim (a claim where services, drugs, or supplies have already been provided). Please refer to Section 8 of the Service Benefit Plan brochure for detailed information about the disputed claims process. Please
note that you must write to us within 6 months from the date of our decision.
Provider appeal submission form - Providers, use this form to dispute a denied claim or processed claim that negatively impacts your payment. Please do not use
this form for corrected claims, duplicate claim denials, claims requests for additional information, coordination of benefits, or claims submission inquiries, as these are not considered provider appeal issues.
Request for inspection of records - Use this form to request certain records that we maintain containing your personal information.
Request for amendment of records - Use this form to request a change to your personal information that we maintain, if you think we have incorrect or incomplete
Disclosure accounting request - Use this form to request a record of how we disclosed information about you for reasons other than our normal business functions.
Pre-approval request/response - generic - Use this form to submit a general pre-approval request.
Pre-approval request/response - hospice - Use this form to submit a hospice pre-approval request.