Capital Blue Cross Printable Forms
This page contains printable forms you can use to manage your accounts at Capital Blue Cross.
Forms List
| File Name | Description |
|---|---|
| ACH Addendum - Capital Blue Cross.pdf | If you wish to have different ACH accounts assigned to different locations, complete this form. |
| ACH Authorization Agreement - Capital Blue Cross.pdf | Groups complete this agreement to authorize an ACH transfer. |
| Authorization for Release of Information - Capital Blue Cross.pdf | Members use this form to allow Capital Blue Cross to release their account information to another person. |
| Capital Blue Cross Group Plan Change Form.pdf | Groups may use this form to make change to their plans. |
| DCFSA Claim Form - Capital Blue Cross.pdf | Members can complete this form to file a DCFSA claim. |
| DCFSA Enrollment Form - Capital Blue Cross.pdf | Members complete this form to enroll in a DCFSA account. |
| Debit Card Request Form - Capital Blue Cross.pdf | Complete this form to request a debit card for an account. |
| Direct Deposit Authorization Form - Capital Blue Cross.pdf | Use this form to authorize a bank account for direct deposit transactions. |
| Electronic Contribution Instructions - Capital Blue Cross.pdf | Use this to help fill out the contribution spreadsheet on the Group Portal. |
| Electronic Deduction and Contribution Template - Capital Blue Cross.xlsx | Use this spreadsheet to upload deduction and contribution information on the Group Portal. |
| FSA Enrollment Form - Capital Blue Cross.pdf | Members complete this form to enroll in a medical FSA plan. |
| FSA PDG - Capital Blue Cross.pdf | Complete this plan design guide to create an FSA plan for a group. |
| Group Contact Change Form - Capital Blue Cross.pdf | Complete this form if there is a change for your group's contact. |
| Group Copay Form - Capital Blue Cross.pdf | Groups complete this form to establish copay amounts for different plans. |
| Group Disband Notice - Capital Blue Cross.pdf | Use this form to terminate one or all of your plans. |
| Group Location Addendum - Capital Blue Cross.pdf | Groups complete this form if the group's contact information has changed. |
| Group Structure Form - Capital Blue Cross.pdf | Use this form to list the structure for groups who hold enrollment for employees being offered health spending account products. |
| Health Plan Deductible Verification Form - Capital Blue Cross.pdf | Use this form to verify that you're deductible has been met, so your account is no longer considered "limited". |
| HRA PDG - Capital Blue Cross.pdf | Complete this plan design guide to create an HRA plan for a group. |
| HSA Beneficiary Designation Form - Capital Blue Cross.pdf | Members complete this form to designate beneficiaries for their account. |
| HSA Employee Contribution Election Form - Capital Blue Cross.pdf | Employees fill out this form and give it to the employer to make an HSA contribution. |
| HSA PDG - Capital Blue Cross.pdf | Complete this plan design guide to create an HSA plan for a group. |
| HSA Rollover Certification Form - Capital Blue Cross.pdf | Use this form to roll funds from one account into an HSA. |
| HSA Transfer Request - Capital Blue Cross.pdf | Complete this form to transfer an HSA account to Capital Blue Cross. |
| HSA Withdrawal Request Form - Capital Blue Cross.pdf | Complete this form to request a withdrawal from an HSA. |
| Letter of Medical Necessity - Capital Blue Cross.pdf | A medical provider must complete this letter to verify that certain expenses are eligible for spending account reimbursement. |
| Medical Expense Reimbursement Claim Form - Capital Blue Cross.pdf | Complete this form to file a reimbursement claim from your spending account. |
| One Time IRA to HSA Rollover Request - Capital Blue Cross .pdf | Form required to rollover funds from an IRA to an HSA. |
| Orthodontia Worksheet - Capital Blue Cross.pdf | This worksheet can help you plan for orthodontia expenses. |
| Qualifying Event Notification - Capital Blue Cross.pdf | Use this form to notify us of an event that could qualify a member for a spending account change. |
| Reimbursement Return Form - Capital Blue Cross.pdf | Use this form if a member receives a reimbursement but wants to return it. |
| Secure File Transfer Information - Capital Blue Cross.pdf | Use this form to complete an SFT request. |
| SFTS Upload Instructions (Distribution-Files).pdf | Groups use these instructions to send a Secure File Transfer to us. |
| Small Group Plan Change Form - Capital Blue Cross.pdf | Small groups use this form to notify us of a plan change. |
| Spanish - DCFSA Claim Form - Capital Blue Cross.pdf | Spanish language version of the form members can use to file a DCFSA claim. |
| Spanish - Debit Card Application Form - Capital Blue Cross.pdf | Spanish language version of the form members can use to apply for a debit card. |
| Spanish - Direct Deposit Authorization Form - Capital Blue Cross.pdf | Spanish language version of the form members can use to authorize direct deposit. |
| Spanish - FSA Enrollment Form - Capital Blue Cross.pdf | This is the Spanish language version of the FSA enrollment form. |
| Spanish - HSA Withdrawal Request Form - Capital Blue Cross.pdf | This is the Spanish language version of the form members use to request an HSA withdrawal. |
| Spanish - Letter of Medical Necessity - Capital Blue Cross.pdf | This is the Spanish language version of the letter a medical provider must sign to ensure certain expenses are eligible for reimbursement. |
| Spanish - Medical Expense Reimbursement Claim Form - Capital Blue Cross.pdf | This is the Spanish language version of the form members use to file a medical expense reimbursement. |
| Spanish - Reimbursement Return Form - Capital Blue Cross.pdf | This is the Spanish language version of the form that must be completed if a member received a reimbursement but wants to return it. |
| Spanish HSA Transfer Form - Capital Blue Cross.pdf | Native Spanish speakers can use this form to complete an HSA transfer request. |