This page contains printable forms you can use to manage your accounts at Capital Blue Cross.
|If you wish to have different ACH accounts assigned to different locations, complete this form.
|AUTHORIZATION FOR DIRECT DEPOSIT.pdf
|Use this form to authorize a bank account for direct deposit transactions
|AUTOMATED GROUP CLEARING HOUSE (ACH) ONLINE AUTHORIZATION AGREEMENT.pdf
|Groups complete this agreement to authorize an ACH transfer.
|Autorización para depósito directo.pdf
|Spanish language version of the form members can use to authorize direct deposit.
|Capital Blue Cross Group Contact Change Form.pdf
|Complete this form if there is a change for your group's contact.
|CARTA DE NECESIDAD MÉDICA (LETTER OF MEDICAL NECESSITY, LOMN).pdf
|This is the Spanish language version of the letter a medical provider must sign to ensure certain expenses are eligible for reimbursement.
|CUENTA DE AHORROS PARA LA SALUD SOLICITUD DE RETIRO.pdf
|This is the Spanish language version of the form members use to request an HSA withdrawal.
|DAYCARE EXPENSE REIMBURSEMENT CLAIM FORM.pdf
|Members can complete this form to file a DCAP claim.
|DEBIT CARD REQUEST FORM.pdf
|Complete this form to request a debit card for an account.
|DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT ENROLLMENT FORM.pdf
|Members complete this form to enroll in a DCAP account.
|Use this form to terminate one or all of your plans.
|Electronic Contribution Instructions - Capital Blue Cross.pdf
|***Use this to help fill out the contribution spreadsheet on the Group Portal.
|Electronic Deduction and Contribution Template - Capital Blue Cross.xlsx
|***Use this spreadsheet to upload deduction and contribution information on the Group Portal.
|FLEXIBLE SPENDING ACCOUNT (FSA) PLAN DESIGN GUIDE.pdf
|Complete this plan design guide to create an FSA plan for a group.
|FORMULARIO DE DEVOLUCIÓN DE REEMBOLSOS.pdf
|This is the Spanish language version of the form that must be completed if a member received a reimbursement but wants to return it.
|FORMULARIO DE RECLAMODE LA CUENTA DE REEMBOLSODE GASTOS MÉDICOS.pdf
|This is the Spanish language version of the form members use to file a medical expense reimbursement.
|FSA Enrollment Form Spanish.pdf
|This is the Spanish language version of the FSA enrollment form.
|FSA Enrollment Form.pdf
|Members complete this form to enroll in a medical FSA plan.
|GROUP COPAY FORM.pdf
|Groups complete this form to establish copay amounts for different plans.
|Group Plan Change Form.pdf
|Use this form for any changes you wish to make to your plan for the upcoming year.
|GROUP STRUCTURE FORM.pdf
|Use this form to list the structure for groups who hold enrollment for employees being offered health spending account products.
|HEALTH PLAN DEDUCTIBLE TAX LIMIT VERIFICATION FORM.pdf
|Use this form to verify that you're deductible has been met, so your account is no longer considered limited.
|HEALTH SAVINGS ACCOUNT (HSA) PLAN DESIGN GUIDE.pdf
|Complete this plan design guide to create an HSA plan for a group.
|HEALTH SAVINGS ACCOUNT ROLLOVER CERTIFICATION.pdf
|Use this form to roll funds from one account into an HSA.
|HEALTH SAVINGS ACCOUNT TRANSFER REQUEST.pdf
|Complete this form to transfer an HSA account to Capital Blue Cross.
|HEALTH SAVINGS ACCOUNT WITHDRAWAL REQUEST.pdf
|Complete this form to request a withdrawal from an HSA.
|HSA BENEFICIARY DESIGNATION FORM.pdf
|Members complete this form to designate beneficiaries for their account.
|HSA Employee Contribution Election Form.docx
|This form is used by employees to provide HSA contribution elections to their employer.
|HSA Essential Guide English.pdf
|Introducing the Capital Blue Cross HSA! Click here to review some quick take-aways about your HSA.
|HSA Fact Sheet.pdf
|Fact sheet: Health Savings Accounts (HSAs)
|LETTER OF MEDICAL NECESSITY (LOMN) .pdf
|A medical provider must complete this letter to verify that certain expenses are eligible for spending account reimbursement.
|Medical and Dependent Care FSA Employer Fact Sheet.pdf
|Fact sheet: Flexible Spending Accounts (FSAs)
|Medical Dependent Care FSA Open Enrollment.pptx
|PowerPoint presentation on FSA Open Enrollment.
|MEDICAL EXPENSE REIMBURSEMENT ACCOUNT CLAIM FORM.pdf
|Complete this form to file a reimbursement claim from your spending account.
|Medical FSA Member Worksheet (English).pdf
|Members use this worksheet to help determine how much to contribute to an FSA.
|Medical FSA Member Worksheet (Spanish).pdf
|FSA Worksheet in Spanish.
|Medical FSA Open Enrollment.pptx
|FSA Open Enrollment PowerPoint presentation.
|Member Requested Authorization for Release of Information.pdf
|Members use this form to allow Capital Blue Cross to release their account information to another person.
|ONE TIME IRA TO HSA ROLLOVER REQUEST.pdf
|Form required to rollover funds from an IRA to an HSA.
|This worksheet can help you plan for orthodontia expenses.
|QUALIFYING EVENT NOTIFICATION FORM.pdf
|Use this form to notify us of an event that could qualify a member for a spending account change.
|REIMBURSEMENT RETURN FORM (english).pdf
|Use this form if a member receives a reimbursement but wants to return it.
|Secure File Transfer Information and Agreement Form.pdf
|Use this form to complete an SFT request
|Solicitud de Tarjeta de Débito.pdf
|Spanish language version of the form members can use to apply for a debit card.
|SOLICITUD DE TRANSFERENCIA DE UNA CUENTA DE AHORROS PARA LA SALUD.pdf
|This is the Spanish language version of the form to complete an HSA transfer request.