Due to a planned data migration beginning Friday, July 11 at 11:00 p.m., and continuing through Monday, July 14 at 8:00 a.m., you may experience a delay in your information appearing on CareFirst portals. We expect that changes to member data will be reflected on the portals by Tuesday, July 15. Your patience is appreciated.

Change Healthcare notifying individuals of data breach. Learn more here.

Maryland Group Applications and Forms

A variety of applications and other forms are available.

Please contact your Account Manager or Broker Representative to ensure that you have the correct forms. Please choose from the list below:

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Group & Member Applications - BluePreferred

Average Age/Factor Adjustment Form

Exclusions/Limitations Document

Miscellaneous Forms - BluePreferred

BlueChoice Advantage and BlueChoice Advantage 2.0

Group & Member Applications - BlueChoice Advantage

Miscellaneous Forms - BlueChoice Advantage

BlueChoice HMO and BlueChoice HMO Open Access

Group & Member Applications - BlueChoice HMO and BlueChoice HMO Open Access

Average Age/Factor Adjustment Form

Miscellaneous Forms - BlueChoice HMO and BlueChoice HMO Open Access

BlueChoice Opt-Out Open Access

Group & Member Applications - BlueChoice Opt-Out Open Access

Average Age/Factor Adjustment Form

Miscellaneous Forms - BlueChoice Opt-Out Open Access

BlueChoice Opt-Out Plus Open Access

Group & Member Applications - BlueChoice Opt-Out Plus Open Access

Average Age/Factor Adjustment Form

Miscellaneous Forms - BlueChoice Opt-Out Plus Open Access

Consumer Directed Health Plans (CDH)

BluePreferred Group & Member Applications and Enrollment Forms
BlueChoice HMO Open Access Group & Member Applications and Forms
BlueChoice Opt-Out Plus Open Access Group & Member Applications and Forms
BlueChoice Advantage Group and Member Applications and Enrollment Forms

Grandfathering Notice of Intent Forms

Group Grandfathering Notice of Intent Forms

HealthyBlue HMO, 2.0 and Triple Option - Group & Member Applications

HealthyBlue Advantage - Group & Member Applications

HealthyBlue PPO - Group & Member Applications

Average Age/Factor Adjustment Form

HealthyBlue Miscellaneous Forms

Group & Member Applications - Preferred (PPO), Traditional, BlueDental Plus, BlueDental EPO & BlueDental Basic

Group & Member Applications - BlueDHMO

Group & Member Applications - Vision

Flexible Spending Account

Flexible Spending Account (FSA) Proposal Request Form

FSA Plan Design Guide

Disclosure Statements

BlueChoice Renewal Statement

BlueChoice New Sales Statement

CareFirst (PPN, MPOS, BluePreferred) Renewal Statement

CareFirst (PPN, MPOS, BluePreferred) New Sales Statement

Preferred Provider Network (PPN)

Member Applications - Preferred Provider Network

Protected Health Information (PHI) Forms

Authorization Form for Information Release

Personal Representative Form

Revocation Authorization Personal Representative Designation

Access to PHI Form

Accounting of Disclosures

Amendment to PHI Form

Restrict PHI Form

Terminate Restriction to PHI Form

Request for Confidential Communications Form

This form should be returned to:

CareFirst BlueCross BlueShield
Privacy Office
PO Box 14858
Lexington, KY 40512
Fax: 1-410-505-6692

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