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Blue Cross and Blue Shield of Vermont Learning Center

Blue Cross Blue Shield of Vermont Printable Forms

This page contains printable forms that you can use to manage your accounts.

Forms List

File NameDescription
ACH ADDENDUM.pdfWhen making changes to your ACH setup, use this form.
ACH DISPUTE FORM.pdfUse this form to file a dispute with an ACH transaction.
AFFIDAVIT OF FINANCIAL TRANSACTION CARD NON-USE OR FRAUD.pdfMembers complete this form if filing a fraud claim on their debit card.
APPEAL FORM.pdfForm to use when a member wants to appeal a denied claim.
AUTHORIZATION FOR DIRECT DEPOSIT.pdfMembers complete this form to authorize direct deposit transactions.
AUTORIZACIÓN PARA DEPÓSITOS DIRECTOS.pdfSpanish-speaking members complete this form to authorize direct deposit transactions.
BCBSVT GROUP CONTACT CHANGE FORM.pdfUse this form to update your group's contact person.
CardHolder Agreement.pdfCardholder agreement for 2023
COVERAGE CHANGE FORM.pdfMembers complete this form when their health plan coverage changes.
CUENTA DE AHORROS PARA LA SALUD SOLICITUD DE RETIRO.pdfSpanish version of the form used when a member wants to make a withdrawal from an HSA.
DAYCARE EXPENSE REIMBURSEMENT CLAIM FORM.pdfThis form must be completed to request a reimbursement from a DCAP.
DISBAND NOTICE.pdfForm to use when terminating an agreement with Blue Cross Blue Shield of Vermont.
ELECTRONIC ACH EFT OR WIRE TRANSFER FORM.pdfThis form should be included when sending an electronic ACH or wire transfer.
Electronic Contributions Instructions BCBSVT.pdfThese are the instructions for filling out the spreadsheet for uploading contribution and deduction information.
Electronic Deduction and Contribution Template Vermont.xlsxFill out this spreadsheet to upload contribution and deduction information to the Group Portal.
EMPLOYEE TERMINATION NOTICE FORM.pdfUse this form to notify us when an employee has been terminated.
FLEXIBLE SPENDING ACCOUNT (FSA) PLAN DESIGN GUIDE.pdf**Fill this out when you're starting a new FSA plan.
FLEXIBLE SPENDING ACCOUNT ENROLLMENT FORM.pdf**You can use this form to enroll in a Medical or Dependent Care FSA (DCAP)
FLEXIBLE SPENDING ACCOUNT TRANSFER OF ADMINISTRATION ADDENDUM.pdfGroups can complete this form when they change their FSA administrator.
FORMULARIO DE DEVOLUCIÓN DE REEMBOLSOS.pdfSpanish version of the form used when a reimbursement must be returned.
FORMULARIO DE RECLAMO DE LA CUENTA DE REEMBOLSO DE GASTOS MÉDICOS.pdfSpanish version of the form used when a member wants to submit a reimbursement claim.
FORMULARIO DE SOLICITUD DE TARJETA DE DÉBITO.pdfSpanish-speaking members complete this form to apply for a debit card.
FSA Electronic File Format Instructions BCBSVT.docxUse these instructions to fill out FSA enrollment files.
GROUP ACCOUNT STRUCTURE.pdfSet up your group's account structure.
GROUP PLAN CHANGE FORM.pdfUse this form to make any changes you wish to make to your plan for the upcoming year.
HEALTH REIMBURSEMENT ARRANGEMENT (HRA) PLAN DESIGN GUIDE.pdfFill this out when you're starting a new HRA plan.
HEALTH SAVINGS ACCOUNT (HSA) PLAN DESIGN GUIDE.pdfFill this out when you're starting a new HSA plan.
HEALTH SAVINGS ACCOUNT CONTRIBUTION FORM.pdfMembers fill out this form to make a non-payroll HSA contribution.
HEALTH SAVINGS ACCOUNT CONTRIBUTION RECOUPMENT FORM.pdfThis form must be completed to recoup money sent to a member.
HEALTH SAVINGS ACCOUNT ROLLOVER CERTIFICATION.pdfUse this form to roll funds from one account into an HSA.
HEALTH SAVINGS ACCOUNT TRANSFER REQUEST.pdfUse this form to transfer funds from another account into a BCBSVT HSA.
HEALTH SAVINGS ACCOUNT WITHDRAWAL REQUEST.pdfThis form allows members to withdraw funds from their HSA.
HEALTH SAVINGS ACCOUNTS CONTRIBUTION FORM.pdfUse this form to manually submit HSA contributions via check.
HRA TRANSFER OF ADMINISTRATION ADDENDUM.pdfUse this form when your group is transferring HRA administrators to BCBSVT.
HSA BENEFICIARY DESIGNATION FORM.pdfDesignate or update your HSA beneficiary information.
HSA Privacy Policy Opt-Out.pdfMembers complete this form to opt out of information sharing with third parties.
LETTER OF MEDICAL NECESSITY (LOMN).pdfThis letter must be signed by a doctor to confirm the reimbursement eligibility of certain expenses.
Location Addendum.pdfUse this to update your group's location information.
MEDICAL EXPENSE REIMBURSEMENT ACCOUNT CLAIM FORM 99999.pdfUse this form to request a reimbursement for an eligible medical expense.
Member Requested Authorization for Release of Information.pdfA member must complete this form to authorize us to release the member's information to someone else.
ONE TIME IRA TO HSA ROLLOVER REQUEST.pdfComplete this form to submit a one-time rollover request from an IRA into an HSA.
Opción pagar al proveedor Para el reembolso de gastos de atención médica.pdfSpanish version of the form used to establish their provider payment elections.
ORTHODONTIA WORKSHEET.pdfUse this worksheet to determine the amount of orthodontia expenses that can be claimed during the upcoming plan year under your medical FSA.
PREMIUM ONLY PLAN DESIGN GUIDE.pdfThis is the plan design guide to fill out when setting up a new Premium Only Plan.
RECLASSIFICATION OF HSA FUNDS.pdfThis form should be used to reclassify previous distributions from an HSA.
REIMBURSEMENT RETURN FORM.pdfUse this form when a reimbursement must be returned.
Secure File Transfer Information.pdfUse this form to agree to the legal terms for a secure file transfer.



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