Other Forms

Accident/Worker's Compensation (Subrogation) Questionnaire

Accident/Worker's Compensation (Subrogation) Questionnaire
Accidente/Trabajador's Compensación (Subrogación) Cuestionario

Bank Draft Agreement

Bank Draft Agreement
Personal BluePlanSM members should send their Bank Draft Agreements to:

Personal BluePlan
P.O. Box 61153
Columbia, SC 29260-1153

Medicare Supplement members should send their Bank Draft Agreements to:

Consumer Products Business Unit
P.O. Box 100133
Columbia, SC 29202-3133

Protected Health Information Forms

For Individuals and Employees of Businesses with 2-50 Employees

Authorization To Disclose Protected Health Information For Underwriting
Autorización Para Revelar Información Protegida De Salud Para Aseguramiento

Authorization To Disclose Protected Health Information To A Third Party

Autorización Para Revelar Información Protegida De Salud a Terceros

For Employees of Businesses with 50 or More Employees

Authorization to Disclose Protected Health Information

Request for Continuation of Care Coverage

For Individuals and Employees of Businesses with 2-50 Employees

Continuation of Care for Serious Medical Conditions

For Employees of Businesses with 50 or More Employees

Continuation of Care for Serious Medical Conditions