Blue Cross Blue Shield of Vermont Printable Forms
This page contains printable forms that you can use to manage your accounts.
Forms List
| File Name | Description |
|---|---|
| ACH ADDENDUM.pdf | When making changes to your ACH setup, use this form. |
| ACH DISPUTE FORM.pdf | Use this form to file a dispute with an ACH transaction. |
| AFFIDAVIT OF FINANCIAL TRANSACTION CARD NON-USE OR FRAUD.pdf | Members complete this form if filing a fraud claim on their debit card. |
| APPEAL FORM.pdf | Form to use when a member wants to appeal a denied claim. |
| AUTHORIZATION FOR DIRECT DEPOSIT.pdf | Members complete this form to authorize direct deposit transactions. |
| AUTOMATED GROUP CLEARING HOUSE (ACH) ONLINE AUTHORIZATION AGREEMENT.pdf | Use this form to authorize your group's ACH setup. |
| AUTORIZACIÓN PARA DEPÓSITOS DIRECTOS.pdf | Spanish-speaking members complete this form to authorize direct deposit transactions. |
| BCBSVT GROUP CONTACT CHANGE FORM.pdf | Use this form to update your group's contact person. |
| CardHolder Agreement.pdf | Cardholder agreement for 2023 |
| COVERAGE CHANGE FORM.pdf | Members complete this form when their health plan coverage changes. |
| CUENTA DE AHORROS PARA LA SALUD SOLICITUD DE RETIRO.pdf | Spanish version of the form used when a member wants to make a withdrawal from an HSA. |
| DAYCARE EXPENSE REIMBURSEMENT CLAIM FORM.pdf | This form must be completed to request a reimbursement from a DCAP. |
| DISBAND NOTICE.pdf | Form to use when terminating an agreement with Blue Cross Blue Shield of Vermont. |
| ELECTRONIC ACH EFT OR WIRE TRANSFER FORM.pdf | This form should be included when sending an electronic ACH or wire transfer. |
| Electronic Contributions Instructions BCBSVT.pdf | These are the instructions for filling out the spreadsheet for uploading contribution and deduction information. |
| Electronic Deduction and Contribution Template Vermont.xlsx | Fill out this spreadsheet to upload contribution and deduction information to the Group Portal. |
| EMPLOYEE TERMINATION NOTICE FORM.pdf | Use this form to notify us when an employee has been terminated. |
| FLEXIBLE SPENDING ACCOUNT (FSA) PLAN DESIGN GUIDE.pdf | PLAN DESIGN GUIDE FORM. |
| 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.pdf | Groups can complete this form when they change their FSA administrator. |
| FORMULARIO DE DEVOLUCIÓN DE REEMBOLSOS.pdf | Spanish version of the form used when a reimbursement must be returned. |
| FORMULARIO DE RECLAMO DE LA CUENTA DE REEMBOLSO DE GASTOS MÉDICOS.pdf | Spanish version of the form used when a member wants to submit a reimbursement claim. |
| FORMULARIO DE SOLICITUD DE TARJETA DE DÉBITO.pdf | Spanish-speaking members complete this form to apply for a debit card. |
| FSA Electronic File Format Instructions BCBSVT.docx | Use these instructions to fill out FSA enrollment files. |
| GROUP ACCOUNT STRUCTURE.pdf | Set up your group's account structure. |
| GROUP PLAN CHANGE FORM.pdf | Use this form to make any changes you wish to make to your plan for the upcoming year. |
| HEALTH REIMBURSEMENT ARRANGEMENT (HRA) PLAN DESIGN GUIDE.pdf | Fill this out when you're starting a new HRA plan. |
| HEALTH SAVINGS ACCOUNT (HSA) PLAN DESIGN GUIDE.pdf | Fill this out when you're starting a new HSA plan. |
| HEALTH SAVINGS ACCOUNT CONTRIBUTION FORM.pdf | Members fill out this form to make a non-payroll HSA contribution. |
| HEALTH SAVINGS ACCOUNT CONTRIBUTION RECOUPMENT FORM.pdf | This form must be completed to recoup money sent to a member. |
| HEALTH SAVINGS ACCOUNT ROLLOVER CERTIFICATION.pdf | Use this form to roll funds from one account into an HSA. |
| HEALTH SAVINGS ACCOUNT TRANSFER REQUEST.pdf | Use this form to transfer funds from another account into a BCBSVT HSA. |
| HEALTH SAVINGS ACCOUNT WITHDRAWAL REQUEST.pdf | This form allows members to withdraw funds from their HSA. |
| HEALTH SAVINGS ACCOUNTS CONTRIBUTION FORM.pdf | Use this form to manually submit HSA contributions via check. |
| HRA TRANSFER OF ADMINISTRATION ADDENDUM.pdf | Use this form when your group is transferring HRA administrators to BCBSVT. |
| HSA BENEFICIARY DESIGNATION FORM.pdf | Designate or update your HSA beneficiary information. |
| HSA Privacy Policy Opt-Out.pdf | Members complete this form to opt out of information sharing with third parties. |
| LETTER OF MEDICAL NECESSITY (LOMN).pdf | This letter must be signed by a doctor to confirm the reimbursement eligibility of certain expenses. |
| Location Addendum.pdf | Use this to update your group's location information. |
| MEDICAL EXPENSE REIMBURSEMENT ACCOUNT CLAIM FORM 99999.pdf | Use this form to request a reimbursement for an eligible medical expense. |
| Member Requested Authorization for Release of Information.pdf | A member must complete this form to authorize us to release the member's information to someone else. |
| ONE TIME IRA TO HSA ROLLOVER REQUEST.pdf | Complete 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.pdf | Spanish version of the form used to establish their provider payment elections. |
| ORTHODONTIA WORKSHEET.pdf | Use 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.pdf | This is the plan design guide to fill out when setting up a new Premium Only Plan. |
| RECLASSIFICATION OF HSA FUNDS.pdf | This form should be used to reclassify previous distributions from an HSA. |
| REIMBURSEMENT RETURN FORM.pdf | Use this form when a reimbursement must be returned. |
| Secure File Transfer Information.pdf | Use this form to agree to the legal terms for a secure file transfer. |