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

Discounts

PAI HIPAA Forms

HIPAA-all groups