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Member Submitted Claim Form PDF File

Appeal Form PDF File

Blue Cross Blue Shield Global® Claim Form:

Blue Dental℠ Out-Of-Network Claim Form PDF File

Blue Dental℠ Extra Dental Cleaning Enrollment Form PDF File — If you are pregnant or have diabetes, you may be eligible for an extra dental cleaning at no additional cost to you.

Authorization for Automatic Account Withdrawal Form:

  • Exchange PDF File (If you bought your plan on Healthcare.gov or through your state's exchange)
  • Non-Exchange PDF File (If you did not buy your plan on Healthcare.gov or through your state's exchange)

Individual Health Plan Contract Change Form PDF File

Reporting Health Care Fraud & Abuse

Agent/Agency of Record Transfer Request PDF File

Appeal Form PDF File
See also How to Appeal

Authorization for Disclosure to Housing Authority PDF File
This form is used to authorize Wellmark to disclosure premium information to a housing authority at the request of the individual.

Authorization to Use or Disclose Protected Health Information PDF File
This form is used to authorize Wellmark to release protected health information to an individual or entity other than yourself.

Consent for Care Management and Care Coordination PDF File
This form is used to authorize your provider to disclose protected health information related to substance use disorder to Wellmark.

Personal Representative Appointment and Authorization to Release Protected Health InformationPDF File
This form is used to appoint someone to act on your behalf, as well as to authorize Wellmark to release protected health information to them.