#  Forms and Information 

 



##  Member Forms 

If the form you are looking for is not listed below, [**contact us**](/contact-us "Contact Us") for assistance.

 

 



  [### Subscriber Claim Form

 ](/sites/g/files/omnuum11506/files/hughp/files/subscriber_claim_form.pdf) 

   [### Claim Form Online Submission

 ](/sites/g/files/omnuum11506/files/hughp/files/myblue_factsheet_claims_submission.pdf) International claims excluded. 

 

 

   [### International Claim Form

 ](/sites/g/files/omnuum11506/files/hughp/files/international-claim-form-us.pdf) 

   [### Wellness Reimbursement Form

 ](/sites/g/files/omnuum11506/files/2026-01/Wellness-Reimbursements.pdf) 

   [### Childbirth Classes Claim Form

 ](/sites/g/files/omnuum11506/files/hughp/files/childbirth_class_reimbursement_form.pdf) With the MyBlue App, you can file for reimbursement online. 

 

 

   [### Claim Summary Example

 ](https://www.bluecrossma.org/disclaimer/summary-of-health-plan-payments) How to read a Summary of Health Plan Payments for medical services you’ve received. 

 

 

  

 

 

 

 

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##  Miscellaneous Forms 

 



  [### Cost Estimate Checklist

 ](/sites/g/files/omnuum11506/files/hughp/files/cost_estimate_checklist.pdf) 

   [### Sample 1099-HC Form

 ](/sites/g/files/omnuum11506/files/hughp/files/sample_1099-hc_form.pdf) All tax forms information. 

 

 

   [### Appeals & Grievances

 ](https://www.bluecrossma.org/disclaimer/member-rights-and-responsibilities/appeals-and-grievances) 

   [### Continuity of Care Request Form

 ](https://home.bluecrossma.com/collateral/sites/g/files/csphws1571/files/acquiadam-assets/00-0000_Continuity_of_Care_Request_Form.pdf) If your doctor is leaving our network. 

 

 

   [### Transition of Care for New Members

 ](https://home.bluecrossma.com/collateral/sites/g/files/csphws1571/files/acquiadam-assets/00-0000_Continuity_of_Care_Request_Form.pdf) New members with out-of-network providers. 

 

 

   [### Travel Benefit Reimbursement Form

 ](/sites/g/files/omnuum11506/files/hughp/files/travel_benefit_reimbursement.pdf) Under the medical benefits travel rider, Blue Cross Blue Shield of Massachusetts will reimburse members for certain expenses related to travel to obtain covered services other than routine or preventative care when access to those services is not... 

 

 

  

 

 

 

 

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##  Prescription Forms 

 



  [### Express Scripts Prescription Drug Reimbursement Form

 ](/sites/g/files/omnuum11506/files/hughp/files/express_scripts_reimbursement_form.pdf) 

   [### Prescription Drug Mail Order Form

 ](/sites/g/files/omnuum11506/files/hughp/files/prescription_delivery_order_form.pdf)