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ESC 5500 + Minimum Essential Coverage Logo

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/ESC 5500 Plans) / Formulario de Reclamo de Gastos Médicos (Planes de MEC/ESC 5500)

Prescription Drug Claim Form (Use this form if RxGRP: DISCOUNT is on your ID card.) / Formulario de Reclamo de Recetas Médicas (Utilice este formulario si RxGRP: DISCOUNT está en su tarjeta de identificación.)

Prescription Drug Claim Form (Use this form if RxGRP: BXPAI is on your ID card.)

Prescription Drug Reimbursement Claim Form (MEC)

Prescription Drug Claim Form (ESC 5500)

Wellness and Preventive Reimbursement Claim Form

 

Limited Benefits Forms

Accident Questionnaire-ESC 5500

Coordination of Benefits-ESC 5500

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 / Accidental Loss of Life Claim Form

 

Discounts

Discount program

PAI HIPAA Forms

HIPAA-all groups