Member forms

Find and download commonly used member forms.

We recommend Acrobat Reader to use forms in PDF format.

Individual and Family Plan applications

Medical Plan application

Explore your plan options, determine your eligibility for financial help, get a price quote, and apply for a Blue Shield individual or family plan.

Application for Blue Shield Individual and Family Health Plans, English (Quote on Apply tool)

Application for Blue Shield Individual and Family Health Plans, Spanish (PDF, 645 KB)

Application for Blue Shield Individual and Family Health Plans, Chinese (PDF, 1.1 MB)

Application for Blue Shield Individual and Family Health Plans, Korean (PDF, 1.1 MB)

Application for Blue Shield Individual and Family Health Plans, Vietnamese (PDF, 757 KB)

IFP Declaration of Disability form (PDF, 82 KB)

Release of Personal Health Information

Authorization for the Use or Disclosure of Health Information

Submit this form to authorize (allow) Blue Shield to release your personal and health information according to your instructions. To protect your privacy, Blue Shield requires authorization to release your information.

English (PDF, 97 KB)
Spanish (PDF, 104 KB)
Vietnamese (PDF, 225 KB)
Chinese (PDF, 164 KB)
Hindi (PDF, 133 KB)
Korean (PDF, 137 KB)

AutoPay

Enroll in AutoPay

Log into your Blue Shield account and set up automatic payments for your checking/savings account or credit card.

Beneficiary

Beneficiary change request
Submit this form to add or delete beneficiaries from a term life insurance plan.

Beneficiary change request (PDF, 77 KB)

Beneficiary affidavit
Submit this document when no beneficiary was designated or no designated beneficiary survived the deceased insured.

Beneficiary affidavit (PDF, 119 KB)

Proof of Death forms

Individual and Family Plans
Beneficiaries should submit this form for proceeds after an insured dies. When submitting the form, include an original certified death certificate.

Individual and Family Plan Statement and Notice of Death (PDF, 78 KB)

Group Plans
Group Administrators should submit this form after an employee with Life Insurance dies. When submitting the form, include an original certified death certificate, proof of beneficiary designation, and proof of eligibility.

Proof of Death (PDF, 140 KB)

Claims

Accelerated Death Benefit claim
When an insured person becomes terminally ill before age 60, they may get life benefit proceeds prior to death. Before submitting this form, please see plan benefits for specific eligibility.

Accelerated Death Benefit claim (PDF, 108 KB)

Dismemberment claim
Submit this form when the insured is making a dismemberment claim in conjunction with their Accidental Death & Dismemberment coverage.

Dismemberment claim (PDF, 555 KB)

Vision Benefit claim
Take this form to your appointment to file a claim when getting services from a vision provider that is not in the EyeMed provider network.

Vision Benefit claim (PDF, 134 KB)

Life Insurance forms

Additional contact designation
For Individual and Family Plan Subscribers: Complete this form to add an additional contact person(s) to receive a notice of lapse or termination of your life insurance policy if your premium is not paid.

Life Insurance additional contact designation form (PDF, 511 KB)

Continuity of Care

Continuity of Care brochure

English brochure (PDF, 1.3 MB)
Spanish brochure (PDF, 1.3 MB)
Vietnamese brochure (PDF, 1.3 MB)
Chinese brochure (PDF, 1.3 MB)
Hindi brochure (PDF, 1.3 MB)
Korean brochure (PDF, 1.3 MB)

Continuity of Care application

English application (PDF, 75 KB)
Spanish application (PDF, 628 KB)
Vietnamese application (PDF, 762 KB)
Chinese application (PDF, 726 KB)
Hindi application (PDF, 790 KB)
Korean application (PDF, 692 KB)

Language assistance

No cost language service. You can get documents read to you and some sent to you in your language.

© California Physicians' Service DBA Blue Shield of California 1999-2024. All rights reserved. California Physicians’ Service DBA Blue Shield of California is an independent member of the Blue Shield Association. Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.

Additional links

Additional links

Additional links

Additional links

Member forms

Individual and Family Plan applications

Medical Plan application

Release of Personal Health Information

Authorization for the Use or Disclosure of Health Information

AutoPay

Enroll in AutoPay

Beneficiary

Beneficiary change request Submit this form to add or delete beneficiaries from a term life insurance plan.

Beneficiary affidavit Submit this document when no beneficiary was designated or no designated beneficiary survived the deceased insured.

Proof of Death forms

Individual and Family Plans Beneficiaries should submit this form for proceeds after an insured dies. When submitting the form, include an original certified death certificate.

Group Plans Group Administrators should submit this form after an employee with Life Insurance dies. When submitting the form, include an original certified death certificate, proof of beneficiary designation, and proof of eligibility.

Claims

Accelerated Death Benefit claim When an insured person becomes terminally ill before age 60, they may get life benefit proceeds prior to death. Before submitting this form, please see plan benefits for specific eligibility.

Dismemberment claim Submit this form when the insured is making a dismemberment claim in conjunction with their Accidental Death & Dismemberment coverage.

Vision Benefit claim Take this form to your appointment to file a claim when getting services from a vision provider that is not in the EyeMed provider network.

Life Insurance forms

Additional contact designation For Individual and Family Plan Subscribers: Complete this form to add an additional contact person(s) to receive a notice of lapse or termination of your life insurance policy if your premium is not paid.

Continuity of Care

Continuity of Care brochure

Continuity of Care application

Beneficiary change request
Submit this form to add or delete beneficiaries from a term life insurance plan.

Beneficiary affidavit
Submit this document when no beneficiary was designated or no designated beneficiary survived the deceased insured.

Individual and Family Plans
Beneficiaries should submit this form for proceeds after an insured dies. When submitting the form, include an original certified death certificate.

Group Plans
Group Administrators should submit this form after an employee with Life Insurance dies. When submitting the form, include an original certified death certificate, proof of beneficiary designation, and proof of eligibility.

Accelerated Death Benefit claim
When an insured person becomes terminally ill before age 60, they may get life benefit proceeds prior to death. Before submitting this form, please see plan benefits for specific eligibility.

Dismemberment claim
Submit this form when the insured is making a dismemberment claim in conjunction with their Accidental Death & Dismemberment coverage.

Vision Benefit claim
Take this form to your appointment to file a claim when getting services from a vision provider that is not in the EyeMed provider network.

Additional contact designation
For Individual and Family Plan Subscribers: Complete this form to add an additional contact person(s) to receive a notice of lapse or termination of your life insurance policy if your premium is not paid.