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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.pdfIf you wish to have different ACH accounts assigned to different locations, complete this form.
AUTHORIZATION FOR DIRECT DEPOSIT.pdfUse this form to authorize a bank account for direct deposit transactions
AUTOMATED GROUP CLEARING HOUSE (ACH) ONLINE AUTHORIZATION AGREEMENT.pdfGroups complete this agreement to authorize an ACH transfer.
Autorización para depósito directo.pdfSpanish language version of the form members can use to authorize direct deposit.
CARTA DE NECESIDAD MÉDICA (LETTER OF MEDICAL NECESSITY, LOMN).pdfThis 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.pdfThis is the Spanish language version of the form members use to request an HSA withdrawal.
DAYCARE EXPENSE REIMBURSEMENT CLAIM FORM.pdfMembers can complete this form to file a DCAP claim.
DEBIT CARD REQUEST FORM.pdfComplete this form to request a debit card for an account.
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT ENROLLMENT FORM.pdfMembers complete this form to enroll in a DCAP account.
DISBAND NOTICE.pdfUse 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.pdfComplete this plan design guide to create an FSA plan for a group.
FORMULARIO DE DEVOLUCIÓN DE REEMBOLSOS.pdfThis 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.pdfThis is the Spanish language version of the form members use to file a medical expense reimbursement.
FSA Enrollment Form Spanish.pdfThis is the Spanish language version of the FSA enrollment form.
FSA Enrollment Form.pdfMembers complete this form to enroll in a medical FSA plan.
GROUP CONTACT CHANGE FORM .pdfComplete this form if there is a change for your group's contact.
GROUP COPAY FORM.pdfGroups complete this form to establish copay amounts for different plans.
GROUP STRUCTURE FORM.pdfUse 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.pdfUse 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.pdfComplete this plan design guide to create an HSA plan for a group.
HEALTH SAVINGS ACCOUNT ROLLOVER CERTIFICATION.pdfUse this form to roll funds from one account into an HSA.
HEALTH SAVINGS ACCOUNT TRANSFER REQUEST.pdfComplete this form to transfer an HSA account to Capital Blue Cross.
HEALTH SAVINGS ACCOUNT WITHDRAWAL REQUEST.pdfComplete this form to request a withdrawal from an HSA.
HSA BENEFICIARY DESIGNATION FORM.pdfMembers complete this form to designate beneficiaries for their account.
HSA Employee Contribution Election Form.docxThis form is used by employees to provide HSA contribution elections to their employer.
LETTER OF MEDICAL NECESSITY (LOMN) .pdfA medical provider must complete this letter to verify that certain expenses are eligible for spending account reimbursement.
MEDICAL EXPENSE REIMBURSEMENT ACCOUNT CLAIM FORM.pdfComplete this form to file a reimbursement claim from your spending account.
Member Requested Authorization for Release of Information.pdfMembers use this form to allow Capital Blue Cross to release their account information to another person.
ONE TIME IRA TO HSA ROLLOVER REQUEST.pdfForm required to rollover funds from an IRA to an HSA.
ORTHODONTIA WORKSHEET.pdfThis worksheet can help you plan for orthodontia expenses.
QUALIFYING EVENT NOTIFICATION FORM.pdfUse this form to notify us of an event that could qualify a member for a spending account change.
REIMBURSEMENT RETURN FORM (english).pdfUse this form if a member receives a reimbursement but wants to return it.
Secure File Transfer Information and Agreement Form.pdfUse this form to complete an SFT request
Solicitud de Tarjeta de Débito.pdfSpanish 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.pdfThis is the Spanish language version of the form to complete an HSA transfer request.
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