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Capital Blue Cross Learning Center

Capital Blue Cross Printable Forms

This page contains printable forms you can use to manage your accounts at Capital Blue Cross.

Forms List

File NameDescription
ACH Addendum - Capital Blue Cross.pdfIf you wish to have different ACH accounts assigned to different locations, complete this form.
ACH Authorization Agreement - Capital Blue Cross.pdfGroups complete this agreement to authorize an ACH transfer.
Authorization for Release of Information - Capital Blue Cross.pdfMembers use this form to allow Capital Blue Cross to release their account information to another person.
Capital Blue Cross Group Plan Change Form.pdfGroups may use this form to make change to their plans.
DCAP Claim Form - Capital Blue Cross.pdfMembers can complete this form to file a DCAP claim.
DCAP Enrollment Form - Capital Blue Cross.pdfMembers complete this form to enroll in a DCAP account.
Debit Card Request Form - Capital Blue Cross.pdfComplete this form to request a debit card for an account.
Direct Deposit Authorization Form - Capital Blue Cross.pdfUse this form to authorize a bank account for direct deposit transactions.
Electronic Contribution Instructions - Capital Blue Cross.pdfUse this to help fill out the contribution spreadsheet on the Group Portal.
Electronic Deduction and Contribution Template - Capital Blue Cross.xlsxUse this spreadsheet to upload deduction and contribution information on the Group Portal.
FSA Enrollment Form - Capital Blue Cross.pdfMembers complete this form to enroll in a medical FSA plan.
FSA PDG - Capital Blue Cross.pdfComplete this plan design guide to create an FSA plan for a group.
Group Contact Change Form - Capital Blue Cross.pdfComplete this form if there is a change for your group's contact.
Group Copay Form - Capital Blue Cross.pdfGroups complete this form to establish copay amounts for different plans.
Group Disband Notice - Capital Blue Cross.pdfUse this form to terminate one or all of your plans.
Group Location Addendum - Capital Blue Cross.pdfGroups complete this form if the group's contact information has changed.
Group Structure Form - Capital Blue Cross.pdfUse this form to list the structure for groups who hold enrollment for employees being offered health spending account products.
Health Plan Deductible Verification Form - Capital Blue Cross.pdfUse this form to verify that you're deductible has been met, so your account is no longer considered "limited".
HRA PDG - Capital Blue Cross.pdfComplete this plan design guide to create an HRA plan for a group.
HSA Beneficiary Designation Form - Capital Blue Cross.pdfMembers complete this form to designate beneficiaries for their account.
HSA Employee Contribution Election Form - Capital Blue Cross.pdfEmployees fill out this form and give it to the employer to make an HSA contribution.
HSA PDG - Capital Blue Cross.pdfComplete this plan design guide to create an HSA plan for a group.
HSA Rollover Certification Form - Capital Blue Cross.pdfUse this form to roll funds from one account into an HSA.
HSA Transfer Request - Capital Blue Cross.pdfComplete this form to transfer an HSA account to Capital Blue Cross.
HSA Withdrawal Request Form - Capital Blue Cross.pdfComplete this form to request a withdrawal from an HSA.
Letter of Medical Necessity - Capital Blue Cross.pdfA medical provider must complete this letter to verify that certain expenses are eligible for spending account reimbursement.
Medical Expense Reimbursement Claim Form - Capital Blue Cross.pdfComplete this form to file a reimbursement claim from your spending account.
One Time IRA to HSA Rollover Request - Capital Blue Cross .pdfForm required to rollover funds from an IRA to an HSA.
Orthodontia Worksheet - Capital Blue Cross.pdfThis worksheet can help you plan for orthodontia expenses.
Qualifying Event Notification - Capital Blue Cross.pdfUse this form to notify us of an event that could qualify a member for a spending account change.
Reimbursement Return Form - Capital Blue Cross.pdfUse this form if a member receives a reimbursement but wants to return it.
Secure File Transfer Information - Capital Blue Cross.pdfUse this form to complete an SFT request.
SFTS Upload Instructions (Distribution-Files).pdfGroups use these instructions to send a Secure File Transfer to us.
Small Group Plan Change Form - Capital Blue Cross.pdfSmall groups use this form to notify us of a plan change.
Spanish - DCAP Claim Form - Capital Blue Cross.pdfSpanish language version of the form members can use to file a DCAP claim.
Spanish - Debit Card Application Form - Capital Blue Cross.pdfSpanish language version of the form members can use to apply for a debit card.
Spanish - Direct Deposit Authorization Form - Capital Blue Cross.pdfSpanish language version of the form members can use to authorize direct deposit.
Spanish - FSA Enrollment Form - Capital Blue Cross.pdfThis is the Spanish language version of the FSA enrollment form.
Spanish - HSA Withdrawal Request Form - Capital Blue Cross.pdfThis is the Spanish language version of the form members use to request an HSA withdrawal.
Spanish - Letter of Medical Necessity - Capital Blue Cross.pdfThis is the Spanish language version of the letter a medical provider must sign to ensure certain expenses are eligible for reimbursement.
Spanish - Medical Expense Reimbursement Claim Form - Capital Blue Cross.pdfThis is the Spanish language version of the form members use to file a medical expense reimbursement.
Spanish - Reimbursement Return Form - Capital Blue Cross.pdfThis is the Spanish language version of the form that must be completed if a member received a reimbursement but wants to return it.
Spanish HSA Transfer Form - Capital Blue Cross.pdfNative Spanish speakers can use this form to complete an HSA transfer request.
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