Member forms

Cancel a request to authorize someone else to act on your behalf regarding your medical coverage. 

Make changes to existing membership. Send this form to your Human Resources office.

This form may only be used for the following groups: ABB, Inc., Arvest Bank, HFA-AE, LTD., J.B. Hunt Transport, Inc., and Uniti Group, LLC. Members of other groups should refer to their plan administrator for appeal filing.

This form is for use by members of the Paychex group.

This form is to be submitted for a request of continuation of coverage for dependents with a mental or physical handicap that have exceeded the student age.

Does anyone on your policy have other insurance coverage?

Make an individual request for account of certain disclosures of Protected Health Information (PHI) for non-treatment, payment or healthcare operations purposes by Skai Blue Cross Blue Shield.

Request not to use or restrict health information or to end restriction on use or disclosure of health information maintained by Skai Blue Cross Blue Shield.

Make an individual request to correct or amend a record maintained by Skai Blue Cross Blue Shield.

Make an individual request to inspect health information maintained by Skai Blue Cross Blue Shield.

Request confidential communication of Protect Health Information (PHI) from Skai Blue Cross Blue Shield.

This form may only be used for Walmart employees. 

This form may only be used for Walmart employees. 

Submit claims not filed by a provider.

Request not to use or restrict health information or to end restriction on use or disclosure of health information maintained by Skai Blue Cross Blue Shield.

Request not to use or restrict health information or to end restriction on use or disclosure of health information maintained by Skai Blue Cross Blue Shield.