Member Forms

Our member forms are available to help you manage your health plan— such as coordination of benefits, confidential communications, authorization to release information, and more. Many of the forms are available via the Member Resource Center for easy completion and submission online – eliminating the need for printing and mailing.

If you are an employer looking to enroll new members or make changes to your group’s existing enrollment information, visit our Member Maintenance page.

Forms for Members

Complete the below form and submit via the Member Resource Center, or via email or fax. The Blue Cross and Blue Shield of Vermont claims team accepts some member-submitted claims for covered services with out-of-network (non-preferred) providers. If you need help completing the form, contact our Customer Service team at (800) 247-2583.

• Member Medical Claim Form
• Member Medical Claim Form Submission Checklist
• Prescription Drug Claim Form
  • Online Member Prescription Drug Claim Form
  • PDF Member Prescription Drug Claim Form
  Coordination of Benefits Legal Forms
  • Confidential Communication Request Form
  • Revocation of Confidential Communications
  Prior Approval & Medical Review

  For in-network services, you should work directly with your provider to get prior approval. To check the status of your prior approval request, log in to the Member Resource Center.

  The following forms and resources can be used for understanding Prior Approvals.

  • Adult Dependent Coverage Request
  • Continuity of Care
  • Prior Approval Form
  • List of services, equipment and supplies requiring prior approval (PDF)
  • Drugs Requiring Prior Authorization
  Privacy Protection
  • Affidavit of Next of Kin
  • Affidavit of Surviving Spouse
  • Authorization to Release Information
  • Authorization to Release Information - Psychotherapy Notes
  • Authorization to Release Information - Psychotherapy Notes (Following Termination of Coverage)
  • Authorization to Release Information - Revocation
  • Authorization to Release Information - Termination of Coverage
  Reporting a Change

  Individuals and Families

  How you report a change depends on whether you enrolled directly through us or if you enrolled through Vermont Health Connect. It also depends on the type of change you want to make.

  Enrolled Directly with BlueCross BlueShield of Vermont

  If you're currently enrolled directly with us, reference the table below for how and when you can make changes.

  Change of Information

  • Can be done anytime and doesn't require an open enrollment or special enrollment period
  • Is effective immediately; it may take up to 4 days before the change appears in the member Resource Center
  • Address, email, or phone number changes
  • Primary Care Provider change
  • Name change
  • Gender change
  • Log in to the Member Resource Center and select "Report a Change"
  • You can also use our interactive PDF Enrollment/Change form (for Individuals and Families)

  Life Changes/Events

  • Life changes in your family that impact your coverage - they are considered "qualified life events" and may entitle you to a special enrollment period
  • Must be reported within a certain time frame and the effective date is determined by the type of event
  • Add dependents due to marriage, birth, adoption, guardianship, loss of other coverage
  • Remove dependents due to divorce, obtaining other coverage, death
  1. For Life Changes/Event, we recommend seeing if you qualify for a subsidy through Vermont Health Connect
  2. If you do qualify, you can take advantage of the subsidy through Vermont Health Connect - and you can enroll in a BlueCross BlueShield of Vermont health plan.
  3. If you do not qualify for a subsidy, or do not want to take advantage of the subsidy, you can report a change by logging in to the Member Resource Center or using our Enrollment/Change form (pdf).

  
  Enrolled in a BlueCross BlueShield of Vermont Plan through Vermont Health Connect

  If you enrolled in Blue Cross and Blue Shield of Vermont coverage through Vermont Health Connect (VHC), please report your change(s) of information to VHC.

  If you qualify for special enrollment period (e.g. experience a life change/event), you have two options:

  1. Stay enrolled in your current coverage through VHC and report changes to them
  2. Direct enroll in coverage through BlueCross BlueShield of Vermont

  Members enrolled in Blue Cross and Blue Shield of Vermont coverage through Vermont Health Connect have the option to request their plan administration be transferred to Blue Cross and Blue Shield of Vermont. This means that you would become a direct enroll member and would work directly with us for enrollment, getting bills, paying premiums, and reporting changes. It's important to note, direct enroll members are NOT eligible for any subsidies. To learn more about this option, or for any questions, please contact an exchange consultant at (800) 255-4550. They are available Monday - Friday from 8:00 a.m - 4:30 p.m.
  

  Small Groups

  To submit a change or to enroll an employee in a small group qualified health plan, log in to our Employer Resource Center or use the 2023 Small Group Employee Enrollment/Change Form