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.
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
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