Blue Cross Blue Shield Vermont : Member - Member Forms

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Member Forms

Form		Purpose
Affidavit of Next of Kin(.doc)		Legal attestation to next of kin
Affidavit of Surviving Spouse(.doc)		Legal attestation to surviving spouse
Authorization to Release Information		Legal attestation to release information
Authorization to Release Information - Revocation		Revocation of information release
Coordination of Benefits Questionnaire		Establishes whether or not Coordination of Benefits applies
Chiropractic Plan of Treatment Form		Form for Chiropractic Benefits
Group Enrollment Form		Enrollment form for subscribers
Incapacitated Dependent Form		Allows dependent children to continue on parents’s coverage when they would ordinarily be dropped
Nongroup Coverage Application and Change Form		Main enrollment form for individuals not enrolled as part of a group
Prescription Reimbursement Form		Used by members to get reimbursed for out-of-pocket prescription expenses
Prior Approval - Medical Services Comprehensive Procedure and CPT Code Listing		Medical Services requiring Prior Approval
Prior Approval - DME, Orthotics, and Prosthetics Comprehensive Procedure and CPT Code Listing		DME Orthotics and Prosthetics Requiring Prior Approval
Prior Approval Request Form for Medical Services		Form for Medical Services requiring Prior Approval
Prior Approval Request Form for DME, Orthotics, and Prosthetics		Form for DME Orthotics and Prosthetics requiring Prior Approval
Prior Approval Forms (drug-specific) and Guidelines for Prescription Drugs		Prescription Drugs requiring Prior Approval
Safety Net Application and Change Form		Application form for a very limited number of individuals who lost their coverage through a specific set of circumstances
Statement of Domestic Partnership		Legal attestation used to obtain coverage for domestic partner
Student Certification		Yearly affidavit to continue coverage for adult dependent children who qualify because they are full-time students
Subscriber Claim Form		Form for members to get reimbursed for claims where such was not filed for them

Forms for Catamount & VT Blue 65 Members

Form		Purpose
Catamount Blue^sm Enrollment Application		Form to enroll in Catamount Blue
CMS Creditable Coverage Guidance		Important notice concerning prescription drug coverage
CMS Model Creditable Coverage Notices		Important notice concerning prescription drug coverage
CMS Model Non-Creditable Coverage Notices		Important notice concerning prescription drug coverage
CMS Model Personalized Creditable Coverage Notices		Important notice concerning prescription drug coverage
Nongroup Subscriber Medicare Supplement Application and Change Form		Form to be used for subscription changes
Group Subscriber Medicare Supplement Application and Change Form		Form for a group subscriber's changes

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