If you need assistance completing any forms or have any questions, please call Essential StaffCARE’s toll-free Customer Service Line, 1-866-798-0803, Monday through Friday, 8:30 a.m. to 8:00 p.m. Eastern Time. A translation line is available for most languages.
Accident Questionnaire Form (MVP)
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 Plans) / Formulario de Reclamo de Gastos Médicos (Plan de MEC/MVP)
Prescription Drug Reimbursement Claim Form (Indemnity)
Prescription Drug Reimbursement Claim Form (MEC)
Prescription Drug Claim Form (MVP 5500)
Wellness and Preventive Reimbursement Claim Form
Coordination of Benefits-MVP 5500
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
Term Life / Accidental Loss of Life Claim Form
Access Request Form
Amendment Request Form
Authorization for Marketing (Health Plan)
Authorization Form (Health Plan) (This form is used for psychotherapy notes, chemical dependency and sensitive diagnosis.)
Authorization to Disclose PHI to a Third Party
Complaint Form
Confidential Communication Request
Designation of Authorized Representative to Appeal
Disclosure Accounting Request
Notice of Privacy Practices
Notice of Privacy Practices (Spanish)
Restriction Request