Formularios de miembro
There are forms available for downloading, please scroll down to see them all.
Click on the name of the form to start the download. You must have Acrobat Reader to use these PDF forms.
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.
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, 119 KB)
Spanish (PDF, 121 KB)
Vietnamese (PDF, 248 KB)
Chinese (PDF, 347 KB)
Hindi (PDF, 154 KB)
Korean (PDF, 229 KB)
AutoPay
Enroll in AutoPay
Log in to 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, 43 KB)
Beneficiary Affidavit
Submit this document when no beneficiary was designated or no designated beneficiary survived the deceased insured.
Beneficiary Affidavit (PDF, 37 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, 468 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, 117 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, 451 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, 448 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 MESVision provider network.
Vision Benefit Claim (PDF, 73 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, 443 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, 96 KB)
Spanish application (PDF, 154 KB)
Vietnamese application (PDF, 222 KB)
Chinese application (PDF, 269 KB)
Hindi application (PDF, 307 KB)
Korean application (PDF, 220 KB)
Asistencia de idiomas
Servicios de idiomas sin costo. Puede obtener un intérprete. Le pueden leer documentos y que le envíen algunos en español.
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
Cov Kev Pab Txhais Lus Tsis Them Nqi. Koj yuav thov tau kom muaj neeg los txhais lus rau koj thiab kom neeg nyeem cov ntawv ua lus Hmoob. Yog xav tau kev pab, hu rau peb ntawm tus xov tooj nyob hauv koj daim yuaj ID los sis 1-866-346-7198. Yog xav tau kev pab ntxiv hu rau CA lub Caj Meem Fai Muab Kev Tuav Pov Hwm ntawm 1-800-927-4357 Hmong
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
Беслпатные услуги перевода. Вы можете воспользоваться услугами переводчика, и ваши документы прочтут для вас на русском языке. Если вам требуется помощь, звоните нам по номеру, указанному на вашей идентификационной карте, или 1-866-346-7198. Если вам требуется дополнительная помощь, звоните в Департамент страхования штата Калифорния
(Department of Insurance), по телефону 1-800-927-4357. Russian
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
Các Dịch Vụ Trợ Giúp Ngôn Ngữ Miễn Phí. Quý vị có thể được nhận dịch vụ thông dịch. Quý vị có thể được người khác đọc giúp các tài liệu và nhận một số tài liệu bằng tiếng Việt. Để được giúp đỡ, hãy gọi cho chúng tôi tại số điện thoại ghi trên thẻ hội viên của quý vị hoặc 1-866-346-7198. Để được trợ giúp thêm, xin gọi Sở Bảo Hiểm California tại số 1-800-927-4357. Vietnamese
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
Անվճար Լեզվական Ծառայություններ։ Դուք կարող եք թարգման ձեռք բերել և փաստաթղթերը ընթերցել տալ ձեզ համար հայերեն լեզվով։ Օգնության համար մեզ զանգահարեք ձեր ինքնության (ID) տոմսի վրա նշված կամ 1-866-346-7198 համարով։ Լրացուցիչ օգնության համար 1-800-927-4357 համարով զանգահարեք Կալիֆորնիայի Ապահովագրության Բաժանմունք։ Armenian
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
無料の言語サービス 日本語で通訳をご提供し、書類をお読みします。サービスをご希望の方は、ＩＤカー ド記載の番号または1-866-346-7198までお問い合わせください。更なるお問い合わせは、カリフォルニア州保険庁、1-800-927-4357までご連絡ください。Japanese
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
Servicios de idiomas sin costo. Puede obtener un intérprete. Le pueden leer documentos y que le envíen algunos en español. Para obtener ayuda, llámenos al número que figura en su tarjeta de identificación o al 1-866-346-7198. Para obtener más ayuda, llame al Departamento de Seguros de CA al 1-800-927-4357. Spanish
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
免費語言服務。您可獲得口譯員服務。可以用中文把文件唸給您聽，有些文件有中文的版本，也可以把這些文 件寄給您。欲取得協助，請致電您的保險卡所列的電話號碼，或撥打 1-866-346-7198 與我們聯絡。欲取得其他協助，請致電 1-800-927-4357 與加州保險部聯絡。Chinese
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
무료 통역 서비스. 귀하는 한국어 통역 서비스를 받으실 수 있으며 한국어로 서류를 낭독해주는 서비스를 받으실 수
있습니다. 도움이 필요하신 분은 귀하의 ID 카드에 나와있는 안내 전화: 1-866-346-7198번으로 문의해 주십시오. 보다 자세한
사항을 문의하실 분은 캘리포니아 주 보험국, 안내 전화 1-800-927-4357번으로 연락해 주십시오. Korean
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
Walang Gastos na mga Serbisyo sa Wika. Makakakuha ka ng interpreter o tagasalin at maipababasa mo sa Tagalog ang mga dokumento. Para makakuha ng tulong, tawagan kami sa numerong nakalista sa iyong ID card o sa 1-866-346-7198. Para sa karagdagang tulong, tawagan ang CA Dept. of Insurance sa 1-800-927-4357 Tagalog
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
บริการทางภาษาอย่างไม่เสียค่าใช้จ่าย คุณสามารถรับบริการจากล่าม รวมถึงให้เจ้าหน้าที่อ่านเอกสารให้คุณฟัง
หรือส่งเอกสารบางส่วนในภาษาของคุณไปหาคุณได้ หากต้องการความช่วยเหลือ
กรุณาโทรศัพท์ตามหมายเลขที่ระบุอยู่ด้านหลังบัตรประจําตัวของคุณ หรือ ที่หมายเลข 1-866-346-7198
หากต้องการความช่วยเหลือเพิ่มเติม โปรดโทรมาที่ กรมการประกันภัยแห่งมลรัฐแคลิฟอร ์เนียที่หมายเลข 1-800-927-4357 Thai
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
