Forms for Regence BlueCross BlueShield of Utah Members
|Incident Report Form|
|Your health contract contains a subrogation provision that allows us to recoup claims payments we have made for injuries or illnesses caused by a third party. If another entity or individual may be responsible for your injury or illness, you need to complete an Incident Report. Examples of the types of accidents or illnesses we need to know about include motor vehicle accidents, work-related injuries and illnesses, injuries on another person's property (such as falling in a grocery store), defective products or machinery, and food poisoning.
Please return the complete form:
PO Box 12625 MS S1C
Salem, OR 97309
By Fax: 1 (888) 891-0771
|Incident Report FAQ||Some common questions and answers about this form.|
|Coordination of Benefits/Multiple Coverage Inquiry|
|Coordination of Benefits (COB) is a provision that allows family members covered by two or more health plans to receive up to 100% coverage for healthcare services.
Mail form to:
PO Box 1271, MS-4L
Portland, OR 97207-9861
or FAX: 1 (888) 661-2850
|Coordination of Benefits FAQ||Some common questions and answers about this form.|
|Authorization to Disclose Protected Health Information|
|Authorization to Disclose Protected Health Information
|Use this form to authorize Regence to disclose health information to a designated party for a specific purpose.|
|Prescription Medication Forms|
|Prescription mail-order forms can now be found on theRegenceRx Member Web site.|
|Member Reimbursement Claim Form (PDF)||Use this form to submit claims for covered services (medical, dental, vision or prescription medications) that require you to pay out-of-pocket and submit for reimbursement.
You may mail, email or fax your reimbursement form and receipts to us.
|International Claim Form
|Go to BlueCard® Worldwide and find the International Claim Form you need at the bottom of the page to submit for benefits for covered services received outside the U.S., Puerto Rico, Jamaica and the U.S. Virgin Islands.|
|Appeals and Grievances Form|
Appeals and Grievance Form
Medicare Advantage and most ASO (Alternate Funded Groups) products not applicable
English (Fillable PDF)
Spanish (Fillable PDF)
|Use this form to request an appeal to a coverage determination or to file a complaint/grievance with us.|
|Surepay Information and Authorization Form (PDF)||To set up automatic payment of your premium from your personal account, download and print the SUREPAY Authorization Form, follow the instructions, and mail to:
Regence BlueCross BlueShield of Utah
P.O. Box 1127
Lewiston, ID. 83501-1127
|NetCare Conversion Forms
Outline of Coverage (PDF)
Benefit Summary (PDF)
Enrollment Form (PDF)
Surepay Authorization (PDF)
|NetCare Conversion - for enrollment on or after January 1, 2010.|
|Plan Enrollment and Change Forms|
|Application for Crediting Prior Coverage (PDF)||Use this form to provide information about any health insurance coverage you and/or your dependents have had during the past 24 months.|
|Individual Plan Change Request (PDF)||Use this form to change your current individual plan to lesser benefits.|
|Individual Transfer and Rate Review (PDF)||Use this form if moving to lesser benefits.|
|Use these forms when adding dependent(s) to an Individual/Family plan. Both forms are required.
Section A: Subscriber information only. Include the policy ID# behind Subscribers last name.
Section B-H: These sections must be completed for the dependent(s) being added.
Section I: Subscriber and Spouse (if applicable) must sign and date.
Authorization form: Subscriber, Spouse and any dependent being added that is over the age of 18 must sign and date.
|Dependent Child Certification||Verification of dependent eligibility form.|
|Affidavit of Domestic Partnership||Employees and their domestic partners applying for coverage should complete this form.|
|Affidavit of Qualifying Incapacitated Dependent Eligibility||Use this form to certify that an eligible dependent child is incapacitated due to medical disability, developmental disability or mental disorder.|
|Special Beginnings Enrollment Questionnaire and Prenatal Book Order Form
English version (fillable PDF)
Spanish version (PDF)
|If you are interested in our Special Beginnings Maternity Management program, please complete the enrollment questionnaire and prenatal book order form. After submitting the completed forms, the member will receive tailored educational materials. Please fax the completed enrollment form and prenatal book form to: (801) 333-6511 or mail to:
Regence BlueCross BlueShield of Utah
Attn: Trina Lindquist, Dept. #36
P.O. Box 30270
Salt Lake City, Utah 84130-0270
|COBRA, USERRA or State Continuation Application (fillable PDF)||Use this form when an employee or dependent chooses to continue group coverage after a qualifying event.|