Forms

If you need assistance completing any forms or have any questions, please call Customer Service at 1-866-798-0803. Representatives are available Monday through Friday, 8:30 a.m. to 8:00 p.m. Eastern Time. A translation line is available for most languages.

General Forms

Authorized Representative Form / Formulario de Representante Autorizado

Medical Claim Form (MEC & MVP) / Formulario de Reclamo de Gastos Médicos (MEC & MVP)

Prescription Drug Reimbursement Claim Form (MEC Plan)

Wellness and Preventive Reimbursement Claim Form

Discounts

PAI HIPAA Forms

HIPAA-all groups