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