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

Prescription Drug Claim Form / Formulario de Reclamo de Recetas Médicas

Medical Claim Form / Formulario de Reclamo de Gastos Médicos

Wellness and Preventive Reimbursement Claim Form

Limited Benefits Forms

Accident Questionnaire-ESC 5500 Plan

Coordination of Benefits-ESC 5500 Plan

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

Discounts

PAI HIPAA Forms

HIPAA-all groups