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Forms

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.

General Forms

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

 

Limited Benefits Forms

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

 

HIPAA Forms

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