Forms, Documents & Notices

Forms, Documents & Notices

Benzene Protocol

Blue Cross/Blue Shield International Claim Form

Blue Cross/Blue Shield Medical Claim Form

Delta Dental Claim Form

Fit For Duty Form

MEBA Diagnostic Center Transportation Reimbursement Claim Form

MEBA Medical Plan Address Change Form

MEBA Medical Plan Application for Reimbursement of Pensioner Medical Contributions

MEBA Medical Plan Authorization for the Use and Disclosure of PHI

MEBA Medical Plan Beneficiary Designation Form

MEBA Medical Plan Statement of Claims for Members and Dependents

MEBA Medical Plan Complaint Form

MEBA Medical Plan Confidential Communications Request

MEBA Medical Plan Dependent Parent Supporting Statement

MEBA Medical Plan Designation of Authorized Representative for Claims and Appeals

MEBA Medical Plan Designation of Health Information Recipient Form

MEBA Medical Plan Incident/Accident Report Form

MEBA Medical Plan Medicare Part B Reimbursement Application

MEBA Medical Plan Restriction Request

MEBA Medical Plan Request for Amendment of PHI

MEBA Medical Plan Request for Disclosures of PHI

MEBA Medical Plan Request for Inspection of PHI

MEBA Medical Plan Permanent Data Form

MEBA Medical Plan Short-Term Disability Claim Form for Members

MEBA Medical Plan Spouse Medical Coverage Waiver Form

MEBA Medical Plan Student Status Form

MEBA Medical Plan Subrogation Reimbursement Agreement

MEBA Medical Plan Travel Profile

OptumRx Direct Member Reimbursement Form

OptumRx New Prescription Mail-In Order Form

Meba Medical Plan Request for USCG Drug Test Form

Amendment 23-4 MEBA Medical Plan

Amendment 23-3 MEBA Medical Plan

Amendment 23-2 MEBA Medical Plan

Amendment 23-1 MEBA Medical Plan

Amendment 22-5 MEBA Medical Plan

Amendment 22-4 MEBA Medical Plan

Amendment 22-3 MEBA Medical Plan

Amendment 22-2 MEBA Pension Plan

Amendment 22-1 MEBA Medical Plan

Amendment 21-6 MEBA Medical Plan

Amendment 21-5 MEBA Medical Plan

Amendment 21-4 MEBA Medical

Amendment 21-3 MEBA Medical Plan

Amendment 21-2 MEBA Medical Plan

Amendment 21-1 MEBA Medical Plan

Amendment 20-8 MEBA Medical Plan

Amendment 20-7 MEBA Medical Plan

Amendment 20-6 MEBA Medical Plan

Amendment 20-5 MEBA Medical Plan

Amendment 20-4 MEBA Medical Plan

Amendment 20-3 MEBA Medical Plan

Amendment 20-2 MEBA Medical Plan

Amendment 20-1 MEBA Medical Plan

Amendment 19-2 MEBA Medical Plan

Amendment 19-1 MEBA Medical Plan

Amendment 18-5 MEBA Medical Plan

Amendment 18-4 MEBA Medical Plan

Amendment 18-3 MEBA Medical Plan

Amendment 18-2 MEBA Medical Plan

Amendment 18-1 MEBA Medical Plan

Amendment 17-8 MEBA Medical Plan

Amendment 17-7 MEBA Medical Plan

Amendment 17-6 MEBA Medical Plan

Amendment 17-5 MEBA Medical Plan

Amendment 17-4 MEBA Medical Plan

Amendment 17-3 MEBA Medical Plan

Amendment 17-2 MEBA Medical Plan

Amendment 17-1 MEBA Medical Plan

Amendment 16-9 MEBA Medical Plan

Amendment 16-8 MEBA Medical Plan

Amendment 16-7 MEBA Medical Plan

Amendment 16-6 MEBA Medical Plan

Amendment 16-5 MEBA Medical Plan

Amendment 16-4 MEBA Medical Plan

Amendment 16-3 MEBA Medical Plan

Amendment 16-2 MEBA Medical Plan

Amendment 16-1 MEBA Medical Plan

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Contact Us

MEBA Benefit Plans
1007 Eastern Avenue
Baltimore, MD 21202-4345
(410) 547-9111 or (800) 811-MEBA