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.
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 & MVP Plan) / Formulario de Reclamo de Gastos Médicos (Planes de MEC & MVP)
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.)
Prescription Drug Reimbursement Claim Form (MEC)
Prescription Drug Claim Form (MVP)
Wellness and Preventive Reimbursement Claim Form
Accidental Loss of Limb or Sight Claim Form
Accidental Loss of Limb or Sight Claim Form (Attending Physician's Statement)
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
HIPAA-all groups