Support / Forms / Links
Independence Blue Cross Forms
- Enrollment/Change Form
- Claim Reimbursement Forms
- Point of Service Claim Form
- Personal Choice Out-of-Network Claim Form - Individual
- Personal Choice Out-of-Network Claim Form - Group
- Influenza Vaccine Reimbursement Form
- Application to Continue Coverage for Handicapped Dependent Child
- FutureScripts Prescription Drug Reimbursement Form
- Prescription Mail Service Order Form
- Prescription Drug Medication Request Form
- Authorization to Release Form
- Personal Representative Form
- Guest Membership Application
- IBC / Keystone Medicare Forms
United Concordia Forms
COBRA Model Notices - for Self Administered Groups
- COBRA Model Notice FAQs: https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/cobra-model-notices.pdf
- COBRA Model General Notice: https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/cobra/model-general-notice.docx
- COBRA Model Election Notice: https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/cobra/model-election-notice.docx
- COBRA Model General Notice (Spanish): https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/cobra/model-general-notice-spanish.docx
- COBRA Model Election Notice (Spanish): https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/cobra/model-election-notice-spanish.docx