Individual Forms

IBC Sales Brochure

• Blue Solutions for Small Employers

FBP Business Services Forms

• Membership Termination Notice
• Employee & Dependent Enrollment/Change Form
• Pre-Authorized ACH Debit Form

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
• IBC Waiver Form
• Application to Continue Coverage for Handicapped Dependent Child
• Dependent Verification Form: Student
  • Personal Choice
  • Keystone Health Plan East
• PA Dependent to 30 - Enrollment Form
• Prescription Drug Reimbursement Form
• Prescription Mail Service Order Form
• Influenza Reimbursement Form
• IBC / KHPE Medicare Advantage
  • Personal Choice 65 Disenrollment Form
  • Keystone 65 Disenrollment Form
  • Select Option Disenrollment Form
  • AmeriHealth 65 Disenrollment Form
  • AmeriHealth Advantage Disenrollment Form
  • AmeriHealth Rx Disenrollment 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.