Forms

If you need assistance completing any forms or have any questions, please call HospitalityCARE customer service at 1-888-583-3057. 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.

General Forms

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 (Planes de MEC & MVP)

Prescription Drug Claim Form (Use this form if Rx group ECPAI is on your ID card.) / Formulario de Reclamo de Recetas Médicas (Utilice este formulario si el grupo Rx ECPAI está en su tarjeta de identificación.)

Prescription Drug Claim Form (Use this form if Rx group ECFDRX is on your ID card.)

Prescription Drug Reimbursement Claim Form (MEC)

Prescription Drug Claim Form (MVP)

Wellness and Preventive Reimbursement Claim Form

Limited Benefits Forms

Accidental Dismemberment Claim Form

Accidental Dismemberment Claim Form-Attending Physician's Statement

Accidental Dismemberment Claim Form

Accidental Loss of Limb or Sight Claim Form-Attending Physician's Statement

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