Forms

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

General Forms

Accidental Loss of Limb or Sight Claim Form

Authorized Representative Form / Formulario de Representante Autorizado

Critical Illness Claim Form

Medical Claim Form / Formulario de Reclamo de Gastos Médicos

Prescription Drug Reimbursement Claim Form 

Hospital Indemnity Claim Form (VOYA)

Term Life-Accidental Loss of Life Claim Form

Wellness and Preventive Reimbursement 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