Accident Questionnaire
Authorized Representative Form / Formulario de Representante Autorizad
Coordination of Benefits Form / Coordinación de Beneficios de Forma
Dental Claim Form
Employee Termination Form
Enrollment-Change Card Form / Tarjeta de Inscripción/Cambio
EyeMed Out-of-Network Claim Form
Medical Claim Form / Forma de Demanda Para Beneficios de Grupo Medico
Pre-Existing Information Form / Formulario de Información Sobre Preexistencia
Primary Care Physician Election Form
Short-Term Disability Claim Form / Formulario de Reclamo de Discapacidad a
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