Claim forms and claims-related forms.
Alcon Vivity, PanOptix, ReSTOR® and Toric Lens Claim Form
ID: 30853 (W0318)
Blue Cross Blue Shield Global Core Forms
If you need to file a claim for services provided outside of the United States, you can obtain the necessary forms from the Blue Cross Blue Shield Global Core website. Please have your ID prefix ready to enter before searching for your plan form.
Coordination of Benefits
This form authorizes Horizon BCBS to obtain any and all medical records and information from providers of service and/or hospitals, relating to the subscriber and eligible dependents, to the extent required to administer the Plan.
ID: 3247 (W0312)
Formulario de Reclamaciones de Seguros Médicos para Cuentas Nacionales
ID: ID 3200 (w1106)
Medical Transition Care Benefit Request
Transition Care, also referred to as treatment in progress, is a benefit that allows new subscribers and covered dependents to receive medical care by non-participating providers at the in-network benefit level for treatment of an acute injury or illness. Transition care is short term and not intended to replace the regular provisions of the program.
ID: 7164 (0320)
Request for Continuance of Enrollment for a Disabled Dependent
ID: 9429 (W0718)