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Blue Cross Blue Shield of Vermont Printable Forms

This page contains printable forms that you can use to manage your accounts.

Forms List

File NameDescription
ACH Dispute Form VT.pdfUse this form to file a dispute with an ACH transaction.
ACH Addendum Form VT.pdfWhen making changes to your ACH setup, use this form.
Affidavit of Financial Transaction Card Non-use or Fraud - VT.pdfMembers complete this form if filing a fraud claim on their debit card.
Appeal Form VT.pdfForm to use when a member wants to appeal a denied claim.
Authorization for Information Release Form VT.pdfA member must complete this form to authorize us to release the member's information to someone else.
BCBSVT Disband Notice.pdfForm to use when terminating an agreement with Blue Cross Blue Shield of Vermont.
BCBSVT FSA Plan Design Guide.pdfFill this out when you're starting a new FSA plan.
BCBSVT HRA Plan Design Guide.pdfFill this out when you're starting a new HRA plan.
BCBSVT HSA Plan Design Guide.pdfFill this out when you're starting a new HSA plan.
Coverage Change Form - VT.pdfMembers complete this form when their health plan coverage changes.
DCAP Enrollment Form - VT.pdfComplete this form to enroll in a DCAP plan.
DCAP Claim Form VT.pdfThis form must be completed to request a reimbursement from a DCAP.
Direct Deposit Authorization Form - VT.pdfMembers complete this form to authorize direct deposit transactions.
Electronic Contributions Instructions BCBSVT.pdfThese are the instructions for filling out the spreadsheet for uploading contribution and deduction information.
Electronic Deduction and Contribution Template Vermont.xlsxFill out this spreadsheet to upload contribution and deduction information to the Group Portal.
Electronic ACH Wire Transfer Form VT.pdfThis form should be included when sending an electronic ACH or wire transfer.
Employee Termination Notice Form VT.pdfUse this form to notify us when an employee has been terminated.
FSA Enrollment Form VT.pdfYou can use this form to enroll in a Medical or Dependent Care FSA (DCAP)
FSA Transfer of Administration Addendum VT.pdfGroups can complete this form when they change their FSA administrator.
FSA Electronic File Format Instructions BCBSVT.docxUse these instructions to fill out FSA enrollment files.
FTP Setup Form VT.pdfUse this form to create an FTP transfer.
Group Account Structure VT.pdfSet up your group's account structure.
Group ACH Authorization Form VT.pdfUse this form to authorize your group's ACH setup.
Group Contact Change Form VT.pdfUse this form to update your group's contact person.
Group Location Addendum Form VT.pdfUse this to update your group's location information.
HRA Transfer of Administration Addendum VT.pdfUse this form when your group is transferring HRA administrators to BCBSVT.
HSA Beneficiary Form VT.pdfDesignate or update your HSA beneficiary information.
HSA Contribution Form VT.pdfMembers fill out this form to make a non-payroll HSA contribution.
HSA Transfer Request Form - VT.pdfUse this form to transfer funds from another account into a BCBSVT HSA.
HSA Contribution Check Submission Form VT.pdfUse this form to manually submit HSA contributions via check.
HSA Privacy Opt Out Form VT.pdfMembers complete this form to opt out of information sharing with third parties.
HSA Recoupment Form VT.pdfThis form must be completed to recoup money sent to a member.
HSA Withdrawal Request Form VT.pdfThis form allows members to withdraw funds from their HSA.
IRA-to-HSA Rollover Form - VT.pdfComplete this form to submit a one-time rollover request from an IRA into an HSA.
Letter of Medical Necessity VT.pdfThis letter must be signed by a doctor to confirm the reimbursement eligibility of certain expenses.
Medical Expense Reimbursement Claim Form VT.pdfUse this form to request a reimbursement for an eligible medical expense.
Orthodontia Worksheet VT.pdfUse this worksheet to determine the amount of orthodontia expenses that can be claimed during the upcoming plan year under your medical FSA.
POP PDG VT.pdfThis is the plan design guide to fill out when setting up a new Premium Only Plan.
Reclassification of HSA Funds Form VT.pdfThis form should be used to reclassify previous distributions from an HSA.
Reimbursement Return Form VT.pdfUse this form when a reimbursement must be returned.
Secure File Transfer Information and Agreement Form VT.pdfUse this form to agree to the legal terms for a secure file transfer.
Small Group Plan Changes Form VT.pdfSmall groups can use this form to make changes to their plans.
Spanish Debit Card Application - VT.pdfSpanish-speaking members complete this form to apply for a debit card.
Spanish Direct Deposit Authorization Form - VT.pdfSpanish-speaking members complete this form to authorize direct deposit transactions.
Spanish HSA Withdrawal Request Form VT.pdfUse this form when a member wants to make a withdrawal from an HSA.
Spanish Medical Expense Reimbursement Claim Form VT.pdfFill this out when a member wants to submit a reimbursement claim.
Spanish Pay the Provider Election Form VT.pdfSpanish-speaking members complete this form to establish their provider payment elections.
Spanish Reimbursement Return Form VT.pdfUse this form when a reimbursement must be returned.
Spanish-HSA Withdrawal Request Form VT.pdfSpanish version of the HSA Withdrawal form. This allows members to request funds from their HSA.
VEBA Account Option Form VT.pdfForm for members choosing account options for VEBAs.
VEBA Add Dependent Form VT.pdfUse this form to add dependents to a member's VEBA.
VEBA Beneficiary Form VT.pdfFill this form out to add beneficiaries to a member's VEBA.
VEBA Enrollment Form VT.pdfUse this form to enroll a member in a VEBA plan.

 

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