Member Forms
Administrative Forms
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Affidavit Domestic Partnership
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Automated Payment Option
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Student Dependent Verification Form
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Non-Medicare Subscriber Claim Form
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New York State Out-of-Network Surprise Medical Bill Assignment of Benefits Form
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Health Care Proxy
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COBRA ARPA Eligibility Form
Claims
HIPAA (Health Insurance Portability and Accountability Act)
Pharmacy
Specialty Services
- Coordination of Benefits Questionnaire - must be logged in to your online account to complete.
- Accident Inquiry Information Form - must be logged in to your online account to complete.
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BlueCross BlueShield of Western New York (BCBSWNY) is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal. BCBSWNY is a division of HealthNow New York Inc., an independent licensee of the Blue Cross and Blue Shield Association. BCBSWNY complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia linguistica, Llame al 1-833-735-4515 (TTY 711) 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-833-735-4515 (TTY 711)
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Content last updated July 23, 2019.