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Medical Forms

Enrollment Forms:

Medical Benefits (Non-Medicare) Enrollment
Medicare Supplement Plan Application
Statement of Health Form
Application for Medical Benefits for Adult Children (Under Age 26)

Claim Forms:

Highmark Member Submitted Claim Form(for reimbursement of medical services.)
Highmark Shingles Claim Form(for reimbursement of the Shingles vaccine
BlueCross BlueShield International Claim Form (for reimbursement of foreign medical care only)
Pharmacy Service Claim Form--Please contact Express Scripts at 1.800.939.3781 or log in to your account at to access member submitted pharmacy claim forms.

Other Health Plan Related Forms:

Domestic Partnership Statement of Financial Interdependence Form
Certification of Domestic Partner as Dependent or Non-Dependent
Protected Health Information Release Form