Find and download commonly used member forms. We recommend Acrobat Reader to use forms in PDF format.
Individual and Family Plan applications
Explore your plan options, determine your eligibility for financial help, get a price quote, and apply for a Blue Shield individual or family plan. Individual and Family Plan Application
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)
Log into your Blue Shield account and set up automatic payments for your checking/savings account or credit card.
BeneficiaryBeneficiary 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)
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)
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)
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 EyeMed provider network. Vision Benefit Claim (PDF, 134 KB)
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 Language assistance No cost language service. You can get documents read to you and some sent to you in your language.
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. 1-866-346-7198 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. 1-866-346-7198 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. 1-866-346-7198 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. 1-866-346-7198 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. 1-866-346-7198 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. 1-866-346-7198 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. 1-866-346-7198 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. 1-866-346-7198 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. 1-866-346-7198 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. 1-866-346-7198 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. 1-866-346-7198 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. 1-866-346-7198 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. 1-866-346-7198 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. 1-866-346-7198 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. 1-866-346-7198 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. 1-866-346-7198 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. 1-866-346-7198 1-800-927-4357
© 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.
