Capital Blue Cross Printable Forms
This page contains printable forms you can use to manage your accounts at Capital Blue Cross.
Forms List
| File Name | Description |
|---|---|
| ACH ADDENDUM.pdf | 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. |
| Cardholder Agreement.pdf | |
| 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. |
| DISBAND NOTICE.pdf | 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. |
| ORTHODONTIA WORKSHEET.pdf | 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. |