Member Forms

For plan members with benefits through their workplace  

• Health Claim Form — Use this form to submit claims for any health expenses covered under the provisions of your benefit plan. Note: Claims for vision care and paramedical treatments may also be submitted online through Member Profile.
• Dental Claim Form — Use this form to submit claims for dental expenses if your dentist is not able to submit your claim directly to Pacific Blue Cross. Claims for Orthodontic treatments may also be submitted online through Member Profile.
• Health Spending Accounts — Use the standard health claim form to submit claims under your HSA plan (if applicable) for expenses that are recognized as medical expenses under Canada Revenue Agency (CRA) Income Tax guidelines. Make sure to answer yes to the question “Apply unpaid balance to HSA plan?”
• Accident or Injury Reimbursement Agreement — Complete this form if your health, dental or disability claim is the result of an accident or injury not related to a workplace or automobile incident.
• Accident or Injury Reimbursement Agreement (ICBC) — Health, dental or disability claim for a VEHICULAR accident or injury prior to November 9, 2018.
• Accident or Injury Reimbursement Agreement (WorkSafe) — Health, dental or disability claim for a WORKPLACE accident or injury.
• Custom Orthopedic shoe claiming checklist — Complete this checklist and submit with your claim if you are claiming for orthopedic shoes.
• Custom Foot Orthotics claiming checklist — Complete this checklist and submit with your claim if you are claiming for custom foot orthotics.
• Prior Authorization for High Cost Drugs — Certain new high cost drugs require prior authorization before we can reimburse prescription costs.
• Blue Cross Life Insurance forms from Assumption Life
• Gender-Affirming Care Approval Form — Use this form to request prior approval for Gender-Affirming Care benefits. Please note, a completed form must be submitted to PBC with your first GAC benefits claim, and prior to each GAC surgery claim.

If you purchased a plan for Individuals and Families  

For clients of the First Nations Health Authority (FNHA)

• FNHA – Client Health Claim/Pre-Determination Form

For plan members with National coverage on My PBC Benefits  

If your membership card looks like this, please go to the My PBC Benefits resource page:

For Veteran Affairs, Canadian Forces and RCMP members

For Travel Claims and Out-of-Country/Province claims  

Additional Blood Glucose Test Strips

Please have your Endocrinologist or Diabetes Specialist complete this form to request an additional 100 blood glucose test strips, if circumstances warrant a periodic increase in blood glucose testing beyond your annual limit.

• Additional Blood Glucose Test Strips request form

Glucose Monitoring Systems

If this request is for the Dexcom G6/G7 Continuous Glucose Monitor or the FreeStyle Libre 2 Flash Glucose Monitoring System (Libre 2), please have your Prescriber or Diabetes Specialist complete the BC PharmaCare Special Authority form and apply directly to BC PharmaCare on your behalf.