Member forms

Note: Some employers use customized forms or electronic systems. Please check with your Human Resources office before using one of these forms.

Membership forms

Authorization for Release of Information [pdf]
Request authorization for someone else to act on your behalf regarding your medical coverage.
Cancel Authorized Representative Appointment Form [pdf]
Cancel a request to authorize someone else to act on your behalf regarding your medical coverage.
Change Form [pdf]
Make changes to existing membership. Send this form to your Human Resources office.
Designation of Authorized Appeal Representative [pdf]
Designation of Authorized Appeal Representative - Non-ERISA [pdf]
Enrollment Form [pdf]
Apply for employee coverage through your Human Resources office. Send this form to your Human Resources office.
Incapacitated Dependent Form [pdf]
This form is to be submitted for a request of continuation of coverage for dependents with a mental or physical handicap that have exceeded the student age.
Other Insurance/Coordination of Benefits (COB) [pdf]
Does anyone on your policy have other insurance coverage?

Claim forms

Dental Claim Form [pdf]
For dental claims if your group has dental benefits.
Medical Claim Form [pdf]
Submit claims not filed by a provider.
Prescription claim form [pdf] To make sure eligible claims are paid quickly, please complete and submit this form.
International claim form [pdf]

Privacy forms

Individual Request for Accounting (HIPAA) [pdf] Make an individual request for account of certain disclosures of Protected Health Information (PHI) for non-treatment, payment or healthcare operations purposes by BlueAdvantage.
Individual Request Not to Use or Disclose PHI (HIPAA) [pdf]
Request not to use or restrict health information or to end restriction on use or disclosure of health information maintained by BlueAdvantage.
Individual Request to Correct or Amend a Record (HIPAA) [pdf]
Make an individual request to correct or amend a record maintained by BlueAdvantage.
Individual Request to Inspect Health Information (HIPAA) [pdf]
Make an individual request to inspect health information maintained by BlueAdvantage.
Request for Confidential Communication (HIPAA) [pdf]
Request confidential communication of Protected Health Information (PHI) from BlueAdvantage.

Other forms

Continuity of Care Form [pdf]
Referral Form [pdf]
Your primary care physician should use this form when a referral is required.

Forms for Walmart

Appeal Filing Form
Appeal Filing Form-Spanish
Designation of Authorized Appeal Representative
HIPAA Authorization Form
Walmart Claim Form
Walmart Coordination-of-Benefits Questionnaire

Forms for Tyson

Appeal Filing Form [pdf]
Appeal Filing Form - Spanish [pdf]
Designation of Authorized Appeal Representative [pdf]
Designation of Authorized Appeal Representative - Spanish [pdf]
HIPAA Authorization Form - Tyson [pdf]
Tyson Coordination of Benefits (COB) [pdf]

Notices

We're mobile!

Find care, claims & more with our new app.

Traveling abroad?

Legal notice
Privacy notice
Linking disclaimer
Report fraud and abuse

Accessibility statement

BlueAdvantage Administrators of Arkansas is an Independent Licensee of the Blue Cross and Blue Shield Association and is licensed to offer health plans in all 75 counties of Arkansas.

Linking disclaimer

If you choose to access other websites from this website, you agree, as a condition of choosing any such link or access, that BlueAdvantage Administrators of Arkansas (BAAA) is not and shall not be responsible or liable to you or to others in any way for your decision to link to such other websites. You further agree that BAAA and its affiliates, its directors, officers, employees and agents ("the BAAA Parties") are not responsible for the content of any other website to which you may link, nor are BAAA or the BAAA Parties liable or responsible under any circumstances for the activities, omissions or conduct of any owner or operator of any other website. Once you choose to link to another website, you understand and agree that you have exited this website and are no longer accessing or using any BAAA Data. You understand and agree that by making any third-party website link available as an option to you, BAAA does not in any way endorse any such website, nor state or imply that you should access such website or any services, products or information which may be offered to you through such other websites or by the owner or operator of such other websites. The owners or operators of any other websites (not BAAA) are solely responsible for the content and operation of all such websites. BAAA makes no warranties or representations of any kind, express or implied, nor of merchantability or fitness for a particular purpose, nor of non-infringement, with regard to the content or operation of any other website to which you may link from this website.

IE support ending soon

Important: Blueprint Portal will not load if you are using Internet Explorer.

Looks like you're using an old browser. The site may not work properly. The Internet Explorer 11 browser application will be retired and go out of support on June 15, 2022. We're encouraging our users to go ahead and switch to Microsoft Edge, Google Chrome, Safari or Firefox.