If you need assistance completing any forms or have any questions, please call Essential StaffCARE customer service at 1-888-208-1998. 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.
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/ESC5500 Plans) / Formulario de Reclamo de Gastos Médicos (Planes de MEC/ESC5500)
Prescription Drug Claim Form (Use this form if Rx group ECPAI is on your ID card.) / Formulario de Reclamo de Recetas Médicas (Utilice este formulario si el grupo Rx ECPAI está en su tarjeta de identificación.)
Prescription Drug Claim Form (Use this form if Rx group ECFDRX is on your ID card.)
Prescription Drug Reimbursement Claim Form (MEC)
Prescription Drug Claim Form (ESC5500)
Wellness and Preventive Care Reimbursement Claim Form
Accident Questionnaire Form (ESC5500)
Coordination of Benefits Form (ESC5500)
Dental Claim Form
Missed Premium Direct Payment Form / Formulario Para el Pago Directo de Primas no Cubiertas
MEC Plan Missed Contribution Direct Payment Form (For weekly payroll deducted MEC plans only.)
Short-Term Disability/Proof of Loss Form
Term Life / Accidental Loss of Life Claim Form
Vision Claim Form