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.
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 Plan) / Formulario de Reclamo de Gastos Médicos (Planes de MEC)
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)
Wellness and Preventive Reimbursement Claim Form
Dental Claim Form
EyeMed Out-of-Network 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
HIPAA-all groups