Skip to content

Medical StaffCARE Logo


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 / Formulario de reclamo por pérdida accidental de miembros

Accidental Dismemberment Claim Form-Physician's Statement

Accidental Loss of Limb or Sight Claim Form / Formulario de reclamo por pérdida de un miembro o de la vista por accidente

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

Authorized Representative Form / Formulario de Representante Autorizado

Dental Claim Form / Formulario de reclamo dental

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 / Cómo presentar un reclamo por discapacidad a corto plazo

Term Life-Accidental Loss of Life Claim Form / Formulario de reclamo del seguro de vida y seguro por muerte accidental

Termination-Loss of Coverage Form / Terminación/pérdida involuntaria de la cobertura



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