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.
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)
Authorized Representative Form / Formulario de Representante Autorizado
Dental Claim Form
EyeMed Out-of-Network Claim Form
Medical Claim Form / Cómo Presentar un Reclamo Médico
Missed Premium Direct Payment Form / Formulario Para el Pago Directo de Primas No Cubiertas
Prescription Drug Claim Form (Use this form if RxGRP: DISCOUNT is on your ID card.)
Prescription Drug Claim Form - (Use this form if RxGRP: BXPAI is on your ID card.) If your Medical plan entitles you to pay a copay at the point of purchase and your prescription was not filed directly to OptumRx by the pharmacy, use this form to submit for payment.
If your Medical plan entitles you to a discount at the point of purchase, and you file your receipts to PAI for reimbursement, please use the Medical Claim Form above.
Please see your Summary Plan Description if you have questions as to which plan is associated with your group.
Short-Term Disability-Proof of Loss Claim Form
Term Life-Accidental Death Claim Form
Termination-Loss of Coverage Form