Highmark Member PDF forms for downloadWe know it can be hard to quickly find the health plan claims and reimbursement forms you’re looking for. That’s why we’ve created this page — to keep our members’ most commonly used forms all in one place. All Highmark members in Pennsylvania, West Virginia, and Delaware can use these forms.

Don’t see the form that you’re looking for? This isn’t a complete list of all member forms, since some may be specific to your Highmark plan. To find other forms, contact the Member Service phone number on the back of your Member ID card.

We’re providing these forms on the blog as a convenience to our members. But don’t forget that you have access to a separate Highmark member site, and the URL is listed on the back of your ID card. The member site also has forms, along with other information about your health plan provider network, claims, coverage, and spending as well as health-and-wellness resources.

Medical Forms

Health Insurance Claim — Fill out and submit along with a detailed list of services from a health care provider when filing a claim.

Send the completed form to the address on the back of your Highmark Member ID card.

If you don’t see an address on your card, send the form to the appropriate address for your region:

  • Pennsylvania (plan code 363 on your card):
    Claims
    P.O.Box 890062
    Camp Hill, PA 17089-0062
  • Pennsylvania (plan code 378):
    Claims
    P.O. Box 890173
    Camp Hill, PA 17089-0173
  • West Virginia (plan code 943):
    Highmark West Virginia
    P.O. Box 7026
    Wheeling, WV 26003-7026
  • Delaware (plan code 070):
    Claims
    P.O. Box 8831
    Wilmington, DE 19899

Major Medical Claim — Request payment of a claim under your Major Medical Insurance policy. Be sure to include a detailed list of the services provided.

International Health Insurance Claim — Through Blue Cross Blue Shield Global Core, file a claim for medical services received outside of the U.S., Puerto Rico, or the U.S. Virgin Islands. Note that you can also fill out this form and gain access to many other resources by using your member ID card to log in at bcbsglobalcore.com.

United Concordia® Dental Claim — Request payment for dental services received outside of the United Concordia network.

Davis Vision Claim — Request payment for vision exams and eyewear received from providers outside of the Davis Vision network.

Childbirth Education Class Reimbursement (including Lamaze) — Pennsylvania, Delaware, and West Virginia Members: Apply for payment for a childbirth education course.

Prescription Drug Forms

Prescription Drug Claim — Request payment when you have paid full price for a prescription drug at a pharmacy. Detail if you are covered by more than one prescription drug plan.

Prescription Drug Medication Request — Some drugs require a medical review by your health plan before you can fill a prescription. Pharmacists call this a “prior authorization.” Ask your doctor to complete a prescription drug medication request. Even better—ask your doctor to enter the request directly to Highmark online through the NaviNet® website to save time!

Zostavax® (Shingles Vaccine) Prescription Drug Claim — Not all doctors carry Zostavax (shingles vaccine). If you purchased the vaccine and took it to a doctor to give you the shot, you can request payment using this form.

Prescription Drug Mail Order Form (and Health, Allergy & Medication Questionnaire) — Save time and money by using a mail order pharmacy to have your medications sent right to your home.

  • Formulario de Pedido de Entrega a Domicilio & Cuestionario sobre la Salud, las Alergias y los Medicamentos (Español)

Premium Payment Forms

Automatic Premium Payment — Highmark health plan members can use e-Billing or Electronic Funds Transfer (EFT) to save time by automating monthly premium payments to deduct from a bank account. Download e-Billing instructions and EFT authorization for your plan:

Spending Account Forms

Flexible Spending Account (FSA) Claim — File a claim for medical, dental, and vision services using a Flexible Spending Account (FSA).

Daycare Claim — File a claim for dependent care (including day care, pre-school, and day camp).

Health Savings Account (HSA) Claim — Submit a medical, dental or vision claim using a Health Savings Account (HSA).

Health Savings Account (HSA) Transfer In — Use this form to transfer funds into a Health Savings Account (HSA). You’ll need your HSA account number to request the transfer. Your account number is located on your welcome letter or online account statements. Transfers are not reported to the IRS. See the General Information section of the form or consult a tax advisor for more information.

Health Savings Account (HSA) Transfer Out — Initiate a trustee-to-trustee transfer of funds from your HSA to a new custodian or trustee. Include your HSA account number, located on your welcome letter or online account statements, to request the transfer. Transfers are not reported to the IRS. See the General Information section of the form or consult a tax advisor for more information.

Health Savings Account (HSA)/Medical Savings Account (MSA) Rollover — Move money from an existing Health Savings Account (HSA) or Medical Savings Account (MSA) to an HSA managed by our custodian. Rollovers are reported to the IRS. See the Rules, Conditions, and Instructions section of the form or consult a tax advisor for more information on avoiding possible tax penalties.

Health Reimbursement Account (HRA) Claim — File a claim for medical, dental, and vision services using a Health Reimbursement Account (HRA).

You also can save time by submitting your spending account claims online through your Highmark account. (This does not include the HSA/MSA Rollover form, though.)

Authorization Forms

Medical Records Transfer Authorization — You’ll need to give written permission anytime you want to transfer your medical records. If you have a new doctor, sharing your health history will help him or her to get to know you better.

Authorization to Disclose Health Information (ADHI) — Use this form to give permission for a spouse/partner, parent, child, or other family member (or another person you authorize) to be able to contact Highmark to get information about your health plan coverage or claims on your behalf. Giving us your authorization in writing helps us to protect your health information and comply with the HIPAA law.

Please note: To give someone access to information about your Spending Account (including balance) or member website (including password reset), please check “Other” in Section 3 of the form, and then write in “Spending Account/Balance” and/or “Member Website/Password.”

The authorization will automatically expire in one year, unless you indicate a different time frame when filling out the form. If you would like authorization to be in place for a shorter or longer period — including for many years, on an ongoing basis — indicate a different “end date” on the form.

Please allow approximately 3-5 business days for Highmark to process your ADHI request and for your authorization to be active in our member information system.