Forms

Medical Claim Form for Group

• Medical Claim Form – English (PDF)
• Medical Claim Form – En Español (Spanish) (PDF)

Behavioral Health Claim Form

• Behavioral Health Claim Form – English (PDF)

Vision – Claim Form

• Vision Claim Form – English (PDF)

Dental HMO – Claim Form

• Dental Claim Form – English (PDF)

Member Reimbursement Form and Foreign Claim Questionnaire

• Member Reimbursement Form and Foreign Claim Questionnaire – English (PDF)

Commercial Grievance Form

• Commercial GRIEVANCE FORM – English (PDF)
• Commercial GRIEVANCE FORM – En Español (Spanish) (PDF)
• Commercial GRIEVANCE FORM – Chinese (PDF)

Continuity of Care Assistance Request Form

• Continuity of Care Assistance Request Form - English (PDF)
• Continuity of Care Assistance Request Form - En Español (Spanish) (PDF)

Disabled Dependent Certification Form

• Disabled Dependent Certification Form - English (PDF)

CVS Caremark Mail Order Pharmacy

• CVS Caremark Mail Order Pharmacy - English (PDF)
• CVS Caremark Mail Order Pharmacy - En Español (Spanish) (PDF)

Prescription Drug Claim Form (Commercial Members)

• Prescription Drug Claim Form (Commercial Members) - English (PDF)
• Prescription Drug Claim Form (Commercial Members) - En Español (Spanish) (PDF)

Authorization For Disclosure of PHI

• Authorization For Disclosure of PHI - English (PDF)
• Authorization For Disclosure of PHI - En Español (Spanish) (PDF)
• Authorization For Disclosure of PHI - Chinese Mandarin - 中文 (PDF)
• Authorization For Disclosure of PHI - Korean - 한국어 (PDF)