Forms

Listed below are forms used to manage your account. When you select a form, an instruction page will appear. Mail or fax the forms to the Pennsylvania Medical Society Insurance Agency.

Highmark Blue Shield Enrollment Application

Highmark Blue Shield Member Change Form

Highmark Blue Shield Claim Form

Highmark Blue Shield Prescription Drug Reimbursement Form

Highmark Blue Shield Prescription Drug Mail Order Form

Davis Vision Claim Form

BlueRx Enrollment Form

BlueRx Prescription Mail Order Form

BlueRx Claim Form

BlueRx Disenrollment Form

Highmark Blue Shield Application for Group Benefits

Highmark Blue Shield Disabled Dependent Certification Form

Highmark Blue Shield Medicare Secondary Payor Questionnaire

United Concordia Application for Group Dental Insurance

United Concordia Enrollment Form

United Concordia Dependent Certification Form

For more information call 866.441.2392 or Ask Us A Question .