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Member Forms

Find the form you need for appeals, claims, disclosures, or other common tasks.

Individual & Family Association

Common forms

Here are the most common forms used by members with individual and family plans.

Claim form *For medical claims, flu shots and other vaccines, please use this form.

Member appeal and authorization form

Declaration of domestic partnership

Prescription drug reimbursement

Express Scripts mail-order form

Common forms

Here are the most common forms used by members of association or employer-based plans.

Member appeal and authorization form

Declaration of domestic partnership

Prescription drug reimbursement

Express Scripts mail-order form

All member forms

Appeals

Member appeal and authorization form

Formulario de apelación del miembro

Independent Review Organization (IRO)

Member complaint form

Complaint and appeal rights

Claims

Incident questionnaire

Other coverage questionnaire

Disclosure and privacy

Authorization for release of psychotherapy notes

Disclosure accounting request

Information release form

Non-disclosure request form

Request for amendment of records

Request for inspection of records

Confidentiality request form

Enrollment and changes

Declaration of domestic partnership

Declaración jurada de parejas de hecho

Individual adult dental copay plan

HSA account application

Tobacco certification form

Department of Retirement Service (DRS)

Application for the addition of family members

Request for certification of disabled dependent

Certificación de dependiente discapacitado

Waiver of coverage

Renuncia la cobertura

Non-smoker certification

Grandfathered plans dental copay listing

Pharmacy

Prescription drug reimbursement

Express Scripts mail-order form

Health, allergy & medication questionnaire

Secondary coverage claim form