Managing Your Medicare Account

ONLINE FORM

Consent Release of PHI for Medicare Plus Blue PPO and Prescription Blue PDP Members

If you have one of our Medicare Plus Blue PPO or Prescription Blue PDP plans and want to access your own PHI or share it with someone you designate, you can fill out this digital form.

ONLINE FORM

Consent Release of PHI for BCN Advantage HMO and HMO-POS Members

If you have one of our BCN Advantage HMO or HMO-POS plans and want to access your own PHI or share it with someone you designate, you can fill out this digital form.

ONLINE FORM

Consent Release of PHI for Blue Cross Medicare Supplement Members

If you have one of our Medicare supplement plans and want to access your own PHI or share it with someone you designate, you can fill out this digital form.

PDF

Member Consent for Release of Protected Health Information for Medicare Members

You can also fill out and send us this printable form if you want to access your PHI.

PDF

Appointment of Representative Form

This form lets you pick a person like a spouse, friend, family member, lawyer or caregiver to act on your behalf regarding Medicare coverage decisions, appeals and grievances. Note: You can't pick a law firm or group to help you.

PDF

Medicare Plus Blue PPO Member Reimbursement Form

If you have a Medicare Advantage PPO plan with us and want reimbursement for a covered medical service, fill out and send this form.

PDF

BCN Advantage HMO and HMO-POS Member Reimbursement Form

If you have a Medicare Advantage HMO or HMO-POS plan with us and want reimbursement for a covered medical service, fill out and send this form.

PDF

Prescription Drugs Claim Reimbursement Form

If you have a Medicare Advantage or Part D plan with us and want reimbursement for a covered drug, download and send this form.

PDF

Member Flu and Pneumonia Shots Reimbursement Form

If you got a flu or pneumonia shot and had to pay for it, fill out and send this form for reimbursement.

PDF

Dental Claim Reimbursement Form

If you have dental coverage with us through your Medicare Advantage plan and want reimbursement for a covered dental service, download and send this form.

PDF

Medicare Supplement Plans Authorization Agreement for Automatic Payments

Pay your Blue Cross Medicare Supplement plan automatically when you fill out and send this form.

How to pay your Medicare Advantage or Part D plan bill

If you have a Medicare Advantage or Part D plan, we don't offer a form for paying your bill. Learn how you can pay your bill with this help document.

Important information about Medicare supplement plans

This is a solicitation of insurance. We may contact you about buying insurance. Blue Cross Medicare Supplement^SM plans aren't connected with or endorsed by the U.S. government or the federal Medicare program.

Y0074_BCBSMBCNWeb_M_2025 CMS Accepted 10012024
Page Last Updated Tue Jan 21 11:51:56 EST 2025

Accessing your Protected Health Information

Consent Release of PHI for Medicare Plus Blue PPO and Prescription Blue PDP Members

Consent Release of PHI for BCN Advantage HMO and HMO-POS Members

Consent Release of PHI for Blue Cross Medicare Supplement Members

Member Consent for Release of Protected Health Information for Medicare Members

Appointing a representative

Appointment of Representative Form

Claims

Medicare Plus Blue PPO Member Reimbursement Form

BCN Advantage HMO and HMO-POS Member Reimbursement Form

Prescription Drugs Claim Reimbursement Form

Member Flu and Pneumonia Shots Reimbursement Form

Dental Claim Reimbursement Form

Paying your bill

Medicare Supplement Plans Authorization Agreement for Automatic Payments

How to pay your Medicare Advantage or Part D plan bill