Forms

Below are forms most commonly used by Boeing members. If you do not find the form you are looking for in this section, please contact Boeing Member Services at 888-802-8776.

Note: You will need Adobe® Acrobat® Reader to view, save, or print a copy of the documents posted on this website. If you do not already have this program, you can download a free copy from Adobe®.


Unless otherwise noted on the form, please send completed forms with any required documentation to:

Blue Cross and Blue Shield of Illinois
P.O. Box 805107
Chicago, IL 60680-4112


Medical Claim Form 
Use this claim form to request reimbursement for applicable medical expenses incurred for services not directly billed to the plan.


Vision Claim Form 
Use this claim form to request reimbursement for applicable vision benefit expenses incurred for services not directly billed to the plan. As of 2014, this form is only used for IAM 751 members in the Selections Plus Plan residing in Kansas. All other plans please visit VSP  for your vision benefit information.


BlueCard Worldwide® International Medical Claim Form 
Use this BlueCard Worldwide® claim form to request reimbursement for applicable medical expenses incurred internationally for services not directly billed to the plan. You have the option be reimbursed in the currency reflected on the bill or U.S. dollars. Your claim reimbursement will be sent to you via a mailed check or electronically deposited to your account via wire transfer. If you choose wire transfer, please be sure to read the instructions carefully and provide all the necessary information to ensure more efficient processing.
Learn more about the international travel and the BlueCard program.


Out-of-Area Dependent Form 
This form is used for SPEEA Members in the Select NetworkSM Plan only. Complete this form for SPEEA dependent children residing outside the Select Network service area.


Disabled Dependent Form 
Use this form to certify disabled dependent status. To help ensure benefits are administered in accordance with your Boeing health care benefit plan, your plan requires annual recertification. Please be sure to completed the Disabled Dependent Form in its entirety, including the accompanying Physician Certification section on the 2nd page.


Coordination of Benefits Questionnaire 
If you or your dependents are covered under more than one medical plan, the plans will work together to coordinate the benefits you receive. To determine if Coordination of Benefits is available and appropriate, BCBS may ask you to complete the Coordination of Benefits questionnaire.


Standard Authorization Form to Use or Disclose Protected Health Information (PHI) 
Complete and submit this form to allow the disclosure of your Personal Health Information (PHI) to a specific person or entity.

 

Mental Health and Substance Abuse Benefits available through ValueOptions 

Your mental health and substance abuse benefits are administered by ValueOptions, not BCBSIL.

  • Locate a Provider in the ValueOptions network 
  • For quicker processing of claims, please remind your provider that claims should be forwarded directly to:
    • ValueOptions
      PO Box 1290
      Latham, NY 12110