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Forms

If you need assistance completing any forms or have any questions, please call EssentialCare’s toll-free Customer Service Line, 1-866-740-4006, Monday through Friday, 8:30 a.m. to 8:00 p.m. Eastern Time. A translation line is available for most languages.

 

General Forms

Authorized Representative Form / Formulario de Representante Autorizado

Medical Claim Form (Indemnity Plan) / Formulario de Reclamo de Gastos Médicos (Plan de Indemnización)

Medical Claim Form (MEC & MVP Plan) / Formulario de Reclamo de Gastos Médicos (Planes de MEC & MVP)

Prescription Drug Claim Form (Use this form if Rx group ECPAI is on your ID card.) / Formulario de Reclamo de Recetas Médicas (Utilice este formulario si el grupo Rx ECPAI está en su tarjeta de identificación.)

Prescription Drug Claim Form (Use this form if Rx group ECFDRX is on your ID card.)

Prescription Drug Reimbursement Claim Form (MEC)

Prescription Drug Claim Form (MVP)

Wellness and Preventive Reimbursement Claim Form

 

Limited Benefits Forms

Accidental Dismemberment Claim Form 

Accidental Dismemberment Claim Form (Attending Physician's Statement)

Accidental Loss of Limb or Sight Claim Form

Accidental Loss of Limb or Sight Claim Form (Attending Physician's Statement)

Dental Claim Form 

EyeMed Out-of-Network Claim Form

Missed Premium Direct Payment Form / Formulario Para el Pago Directo de Primas no Cubiertas

Short-Term Disability/Proof of Loss Form

Term Life or Accidental Death Claim Form

Discounts

Discount program

PAI HIPAA Forms

HIPAA-all groups