Member Forms
Prescription Claim Form
Claim Forms
- D-SNP OTC & Healthy Food Claim FormOpen a PDF
- Medicare Advantage Flex Card Claim FormOpen a PDF
- Medical Claim FormOpen a PDF
- Medicare Advantage Transplant Travel and Lodging Claim formOpen a PDF
- D-SNP Transplant Travel and Lodging Claim formOpen a PDF
- Dental Claim FormOpen a PDF
- International Claim Form (English)Open a PDF
- International Claim Form (Spanish)Open a PDF
General Forms
- Manage Your Privacy
- New York Health Care Proxy form (PDF)Open a PDF
- New York Health Care Proxy form - Spanish (PDF)Open a PDF
Other Forms
Excellus BlueCross BlueShield is an HMO/PPO/HMO D-SNP plan with a Medicare contract and a contract with the New York State Medicaid program. Enrollment in Excellus BlueCross BlueShield depends on contract renewal. Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. Y0028_10519_C.
This page last updated 10-01-2024.
