Downloadable Forms

The forms below are available as PDF files. If you do not have Adobe® Reader®, download it free of charge at Adobe's site.

• Standard Claim Form 

• BlueCard Worldwide® International Claim Form 

• Prescription Drug Claim Form 

• PrimeMail New Prescription Mail-Order Form 

• PrimeMail Refill Prescription Mail-Order Form 

• Request for Coverage for Mentally or Physically Impaired Dependents 

• Coordination of Benefits Form 

• Medicare Coordination of Benefits Form 

• Power of Attorney for Health Care Form  — Designate someone you trust to make health care decisions if you are unable to do so. Follow instructions on the form.

• Standard Authorization Form and other HIPAA Privacy Forms

 

Back to main LANL page | Back to main Members page