If you need assistance completing any forms or have any questions, please call Medical StaffCARE's toll-free Customer Service Line, 1-866-798-0803, 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-Physician's Statement
Accidental Loss of Limb or Sight Claim Form
Accidental Loss of Limb or Sight Claim Form-Physician's Statement
Authorized Representative Form / Formulario de Representante Autorizado
Dental Claim Form
EyeMed Out-of-Network Claim Form
Medical Claim Form / Formulario de Reclamo de Gastos Médicos
Missed Premium Direct Payment Form / Formulario Para el Pago Directo de 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 Loss of Life Claim Form
Termination-Loss of Coverage 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
Confidential Communication Request
Designation of Authorized Representative to Appeal
Disclosure Accounting Request
Notice of Privacy Practices
Notice of Privacy Practices (Spanish)