FBP Kits

The kits below ONLY contain FBP paperwork. See below for the carrier's  paperwork or contact our office for the carrier's paperwork.

Individual Forms

IBC Sales Brochure

• Small Business Product Portfolio

FBP Business Services Forms

• Membership Termination Notice
• Employee & Dependent Enrollment/Change Form
• Independence Blue Cross ACH "Check-o-matic"
• Blue Cross of Northeastern PA ACH "Check-o-matic"

Independence Blue Cross Forms

• KHPE Enrollment/Change Form - This form is no longer available online due to Carrier requirements
• Personal Choice Enrollment/Change Form - This form is no longer available online due to Carrier requirements
• Claim Reimbursement Forms
  • Point of Service Claim Form
  • Personal Choice Out-of-Network Claim Form
• Application to Continue Coverage for Handicapped Dependent Child
• Dependent Verification Form: Student
  • Personal Choice
  • Keystone Health Plan East
• Prescription Drug Reimbursement Form
• Prescription Mail Service Order Form
• Individual Personal Choice - Prime Option

Blue Cross Northeastern of Pennsylvania Forms

• Enrollment/Change form
• Supplemental Form

These forms are in .pdf format, and can be read with Adobe Acrobat, a free reader, which can be downloaded by clicking the icon below.