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Forms

If you need assistance completing any forms or have any questions, please call Essential StaffCARE customer service at 1-866-798-0803. Representatives are available 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 Plan) / Formulario de Reclamo de Gastos Médicos (Planes de MEC)

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)

Wellness and Preventive Reimbursement Claim Form

 

Limited Benefits Forms

Dental Claim Form

EyeMed Out-of-Network Claim Form

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

MEC Plan Missed Contribution Direct Payment Form (For weekly payroll deducted MEC plans only.)

Short-Term Disability/Proof of Loss Form

Term Life / Accidental Loss of Life Claim Form

Discounts

Discount program

PAI HIPAA Forms

HIPAA-all groups