All forms must be signed, then either faxed or mailed.
General forms
FEP claim forms (fepblue.org) - A one-stop source for FEP claim forms.
Other group coverage 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.
Prior Approval
FEP Hearing Aid Authorization Request form – Use this form when requesting hearing aid authorization for services performed in WASHINGTON and ALASKA only. If you are unsure where your services are being performed, please ask your provider or go to fepblue.org/contact to locate your local FEP
Blue Cross Blue Shield customer service phone number for assistance.
Appeals
Member appeal 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.
Medical records
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 information.
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.
Benefit and Claim Information Authorization Release FEP - 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.