Member Forms

  • All forms must be signed, then either faxed or mailed.

    General forms

    FEP forms (fepblue.org) - A one-stop source for FEP claim forms.

    Incident questionnaire - Submit this form if you or a covered dependent has an injury or if a claim is pending for this information.

    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.

    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.

    Authorization for release of healthcare information and records - 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.