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If you need assistance completing any forms or have any questions, please call EssentialCare Customer Service Line, 1-866-740-4006, Monday through Friday, 8:30 a.m. to 8:00 p.m. Eastern Time. A translation line is available for most languages. 

Accidental Dismemberment Claim Form

Accidental Dismemberment Claim Form (Attending Physician's Statement)

Accidental Loss of Limb or Sight Claim Form

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

Authorized Representative Form / Formulario de Representante Autorizado

Dental Claim Form

EyeMed Out-of-Network Claim Form

Medical Claim Form / Cómo Presentar un Reclamo Médico

Missed Premium Direct Payment Form / Formulario Para el Pago Directo ee Primas No Cubiertas

Prescription Drug Claim Form (Use this form if RxGRP: DISCOUNT is on your ID card.)

Prescription Drug Claim Form - (Use this form if RxGRP: BXPAI is on your ID card.) If your Medical plan entitles you to pay a co-pay at the point of purchase and your prescription was not filed directly to OptumRx by the pharmacy, use this form to submit for payment.
If your Medical plan entitles you to a discount at the point of purchase, and you file your receipts to PAI for reimbursement, please use the Medical Claim Form above.
Please see your Summary Plan Description if you have questions as to which plan is associated with your group.

Short-Term Disability-Proof of Loss Claim Form

Term Life-Accidental Death 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