Member Forms
For plan members with benefits through their workplace .
- Health Claim Form — Use this form to submit claims for any health expenses covered under the provisions of your benefit plan. Note: Claims for vision care and paramedical treatments may also be submitted online through Member Profile.
- Dental Claim Form — Use this form to submit claims for dental expenses if your dentist is not able to submit your claim directly to Pacific Blue Cross. Claims for Orthodontic treatments may also be submitted online through Member Profile.
- Health Spending Accounts — Use the standard health claim form to submit claims under your HSA plan (if applicable) for expenses that are recognized as medical expenses under Canada Revenue Agency (CRA) Income Tax guidelines. Make sure to answer yes to the question “Apply unpaid balance to HSA plan?”
- Accident or Injury Reimbursement Agreement — Complete this form if your health, dental or disability claim is the result of an accident or injury not related to a workplace or automobile incident .
- Accident or Injury Reimbursement Agreement (ICBC) — Health, dental or disability claim for a VEHICULAR accident or injury prior to November 9, 2018 .
- Accident or Injury Reimbursement Agreement (WorkSafe) — Health, dental or disability claim for a WORKPLACE accident or injury.
- Custom Orthopedic shoe claiming checklist — Complete this checklist and submit with your claim if you are claiming for orthopedic shoes.
- Custom Foot Orthotics claiming checklist — Complete this checklist and submit with your claim if you are claiming for custom foot orthotics.
- Prior Authorization for High Cost Drugs — Certain new high cost drugs require prior authorization before we can reimburse prescription costs.
- Blue Cross Life Insurance forms from Assumption Life
- Gender-Affirming Care Approval Form — Use this form to request prior approval for Gender-Affirming Care benefits. Please note, a completed form must be submitted to PBC with your first GAC benefits claim, and prior to each GAC surgery claim.
If you purchased a plan for Individuals and Families
- Individual Plan Health Claim Form — Use this form to submit claims for any health expenses covered under the provisions of your benefit plan. Note: Claims for vision care and paramedical treatments may also be submitted online through Member Profile.
- Accidental Loss & Dismemberment Claim - Individual Plans — Use this package if a person insured under and Individual plan with an Accidental Loss/ Dismemberment benefit suffers a loss specified in the policy.
- Life Insurance & Accidental Death Claim Package - Individual Plans — Use this package to submit claims for Term Life and/or Accidental Death benefits included under an Individual plan.
- Personal Health Insurance Pre-Authorized Debit or Credit Card Authorization — Use this form to authorize monthly payments to be withdrawn from your credit card or bank account.
- Personal Health Insurance Declaration of Insurability — For Extended Health Benefits, use this form to add a dependent if it’s beyond the 60 day period of family status change, according to Persons Eligible for Coverage clause in your contract.
- Personal Health Insurance Late Applicants Dental Declaration — For Dental Benefits, use this form to add a dependent if it’s beyond the 60 day period of family status change, according to Persons Eligible for Coverage clause in your contract.
For clients of the First Nations Health Authority (FNHA)
- FNHA – Client Health Claim/Pre-Determination Form
For plan members with National coverage on My PBC Benefits
- National Extended Health Care Claim Form [FORM-210 English] Use this form to submit claims for any health expenses covered under the provisions of your benefit plan.
- National Claim Form (All benefit lines) [FORM-363 English]
- National Claim Form - Health Spending Account [FORM-376 English]
For Veteran Affairs, Canadian Forces and RCMP members
- Health care providers looking for claim forms for Veterans Affairs Canada (VAC), Royal Canadian Mounted Police (RCMP) or Canadian Forces (CF) members can contact our Federal Administered Programs Department by calling 1-888-261-4033 toll free.
RCMP Health Services Mailstop #1208 14200 Green Timbers Way Surrey, BC V3T 6P3
- Canadian Forces members contact and submit your claims to your base Health Care Coordinator.
For Travel Claims and Out-of-Country/Province claims
- Out-of-Country and Out-of-Province Coverage and Claims — Click here to obtain claim forms and instructions for claiming emergency medical expenses.
- Trip Cancellation / Baggage Claim Form - Use this form to claim for Trip Cancellations or Lost Baggages.
- Visitors to Canada Travel Plan Claim Form - Use this form if you are claiming against a Visitors to Canada Travel Plan contract
- Travel Premium Refund Request Form
For Ministry of Social Development & Poverty Reduction or Health Kids Clients
- Alternative Hearing Assistance Supplement or Address Change — Use this form to apply for this supplement or if you are already approved and need to change your address.
Miscellaneous forms
- Blue Chip Drug Eligibility Inquiry Form — Blue Chip plans require prior authorization on certain drugs before we can reimburse prescription costs.
- Individual Plan Pre-Authorized Debit Form — Use this form to provide Pacific Blue Cross with pre-authorization to debit your individual plan premiums from your financial institution.
- Direct Deposit Registration — Sign-in to Member Profile to register for direct deposit, and receive electronic claim statements.
- Request for Claims History — Use this form to request a history of your health or dental claims for up to 5 years or more. NOTE: You can access up to 24 months of claim history for free in Member Profile.
- Sleep Apnea Device Pre-Determination Form — Use this form to request a pre-determination on whether your sleep apnea device will be covered under your benefit plan.
- Member Assignment of Payment Form — When this form is completed and received by Pacific Blue Cross, it allows us to pay a person or party other than the plan holder. All original receipts and invoices must be attached.
Additional Blood Glucose Test Strips
Please have your Endocrinologist or Diabetes Specialist complete this form to request an additional 100 blood glucose test strips, if circumstances warrant a periodic increase in blood glucose testing beyond your annual limit.
- Additional Blood Glucose Test Strips request form
Glucose Monitoring Systems
If this request is for the Dexcom G6/G7 Continuous Glucose Monitor or the FreeStyle Libre 2 Flash Glucose Monitoring System (Libre 2) , please have your Prescriber or Diabetes Specialist complete the BC PharmaCare Special Authority form and apply directly to BC PharmaCare on your behalf.
- CGM INITIAL Request Form — If this is your first time request.
- CGM RENEWAL Request Form — To renew your request after 1 year and subsequent years.
*Electronic claims service is available to all Individual Plan customers and to group plan members whose plan sponsors/employers have opted to provide this service as part of their benefits plan .
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