Level Funded forms

• Request for continuity of care [pdf]
• Designation of Authorized Appeal Representative [pdf]
• Designation of Authorized Appeal Representative - Non-ERISA plan [pdf]
• Change request form [pdf]
• Authorization for release of information [pdf]
• Request for confidential communication of protected health information from BlueAdvantage Administrators of Arkansas [pdf]
• Individual request not to use or disclose (restrict) health information or to end restriction on use or disclosure of health information maintained by BlueAdvantage Administrators of Arkansas [pdf]
• Individual request to inspect health information maintained by BlueAdvantage Administrators of Arkansas [pdf]
• Individual request for accounting [pdf]of certain disclosures of protected health information for non-treatment, payment, or health care operations purposes made by BlueAdvantage Administrators of Arkansas
• Individual request to correct or amend a record maintained by BlueAdvantage Administrators of Arkansas [pdf]
• Authorized representative cancellation form [pdf]
• Exception letter [pdf]
• Medical claim submission form [pdf]