Virginia 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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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

Traditional - NCA Products Only

Group & Member Applications - Traditional NCA Products Only
Miscellaneous Forms - Traditional NCA Products Only

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 CT 10-03
10455 Mill Run Circle
Owings Mills, MD 21117
Fax: 410-505-6692

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