Member Forms

If you need help completing the form, contact our Customer Service team at (800) 247-2583.

• Member Medical Claim Form (pdf)
• Member Medical Claim Form Submission Checklist (pdf)

• Online: Member Prescription Drug Claim Form
• PDF: Member Prescription Drug Claim Form

• Coordination of Benefits and Other Insurance

• Authorization to Release Information
• Authorization to Release Information Following Termination of Coverage
• Authorization to Release Psychotherapy Notes
  • Note: You must also complete the Authorization to Release Information form above with this form
• Authorization to Release Psychotherapy Notes Following Termination of Coverage
• Authorization to Release Substance Use Disorder Records
  • Note: You must also complete the Authorization to Release Information form above with this form
• Authorization to Release Substance Use Disorder Records Following Termination of Coverage
• Revocation of Authorization to Release Information
• Record Access Request Form
• Amendment Request
• Disclosure Accounting Request
• Confidential Communication Request Form
• Revocation of Confidential Communications
• Restriction Request
• Affidavit of Surviving Spouse
• Affidavit of Next of Kin

With the passing of the Paperwork Reduction Act in 2024, the federal government no longer requires physical 1095-B and 1095-C tax forms to be mailed. Blue Cross VT will no longer be proactively sending these forms to our members. We will send proof of minimum essential coverage directly to the Internal Revenue Service (IRS), which will occur by March 31 of each year. No additional action is required by you.

If you would like to request a copy of your 1095 tax form, please call us at (800) 247-2583.

If you enrolled through Vermont Health Connect (VHC) and need a copy of your 1095-A, please contact Vermont Health Connect at (855) 899-9600 or visit the VHC website.

For in-network services, you should work directly with your provider to get prior approval. To check the status of your prior approval request, log in to the Member Resource Center.

The following forms and resources can be used for understanding Prior Approvals. 

• Adult Dependent Coverage Request
• Continuity of Care
• Prior Approval Form
• List of services, equipment and supplies requiring prior approval (PDF)
• Drugs Requiring Prior Authorization

Individuals and Families

How you report a change depends on whether you enrolled directly through us or if you enrolled through Vermont Health Connect. It also depends on the type of change you want to make.

Enrolled Directly with BlueCross BlueShield of Vermont

If you're currently enrolled directly with us, reference the table below for how and when you can make changes.

Enrolled in a BlueCross BlueShield of Vermont Plan through Vermont Health Connect

If you enrolled in Blue Cross and Blue Shield of Vermont coverage through Vermont Health Connect (VHC), please report your change(s) of information to VHC.

If you qualify for special enrollment period (e.g. experience a life change/event), you have two options:

1. Stay enrolled in your current coverage through VHC and report changes to them
2. Direct enroll in coverage through Blue Cross of Vermont

Members enrolled in Blue Cross and Blue Shield of Vermont coverage through Vermont Health Connect have the option to request their plan administration be transferred to Blue Cross and Blue Shield of Vermont. This means that you would become a direct enroll member and would work directly with us for enrollment, getting bills, paying premiums, and reporting changes. It's important to note, direct enroll members are NOT eligible for any subsidies. To learn more about this option, or for any questions, please contact an exchange consultant at (800) 255-4550. They are available Monday - Friday from 8:00 a.m - 4:30 p.m.
 

Small Groups

To submit a change or to enroll an employee in a small group qualified health plan, log in to our Employer Resource Center or use the 2025 Small Group Employee Enrollment/Change Form