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.

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/ESC5500 Plans) / Formulario de Reclamo de Gastos Médicos (Planes de MEC/ESC5500)

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 (ESC5500) 

Wellness and Preventive Care Reimbursement Claim Form

Limited Benefits Forms

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