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Forms

If you need assistance completing any forms or have any questions, please call SimplyMed'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.

 

Authorized Representative Form / Formulario de Representante Autorizado

Caremark Mail Service Order Form

Dental Claim Form

Disability-Loss of Coverage Claim Form

Eye Exam Claim Form

Medical Claim Form

Missed Premium Direct Payment Form

Prescription Drug Claim Form

Term Life-Accidental Death or Dismemberment Claim Form

Termination-Loss of Coverage Claim Form

Discounts

Discount program

PAI HIPAA Forms

HIPAA-all groups