Important Forms

Below are several forms you may need regarding your State Health Plan benefits.

• Eligibility and Enrollment Support Center Authorization Request Form
  If you wish to authorize a person or entity to receive your personal health information (PHI) from the Eligibility and Enrollment Support Center on your behalf, please complete this form.
   
• Member/Dependent Authorization Request Form
  If you wish to authorize a person or entity to receive your PHI from Blue Cross and Blue Shield of NC on your behalf, please complete this form.
   
• Coverage Request for Incapacitated Dependent
  If you have a child over age 26 who is eligible as a mentally or physically incapacitated dependent, complete this form. If you wish to authorize a person or entity to receive your PHI, please complete this form

• Authorize a Representative – Appeals
  Use this form to allow a third party to appeal a denied claim or denied certification on your behalf. Attach this form to the Appeals Form.

• Flexible Benefit Plan (Section 125) Rejection Form
  Learn how to opt out of the Flexible Benefit Plan, IRS Section 125.

• Medication Extended Day Supply Request Form
  Use this form to request an extended day supply of medication when traveling outside of the United States 90 days or more, please complete this form.

Request Reimbursement 

In most cases, health care providers and pharmacies will file your insurance claims for you, and you will pay only your copay out of pocket. However, providers who are not part of the State Health Plan network will ask for full payment directly from you. In those cases, if the services are normally covered by the State Health Plan, you can request that your expenses be reimbursed.

Use the appropriate form below to request reimbursement from the State Health Plan.

• PPO Plan Medical Claim Form
  Use this form to request reimbursement for health care services, such as a visit to a doctor not in the Blue Options provider network. The Plan will only reimburse you up to the allowable, usual, customary, reasonable amount. Non-participating providers may bill you for the remainder of their charges.

• PPO Worldwide International Claim Form
  Use this form to request reimbursement for health care services when you receive care outside of the United States.

• Prescription Drug Claim Form
  Use this form to request reimbursement for prescription drugs, such as those not purchased from a pharmacy contracted with the State Health Plan. Your reimbursement will be the Plan's maximum allowable amount, not the charge for the prescription drug.