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Forms

If you need assistance completing any forms or have any questions, please call Essential StaffCARE 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 (Indemnity Plan) / Formulario de Reclamo de Gastos Médicos (Plan de Indemnización)

Medical Claim Form (MEC/ESC 5500 Plans) / Formulario de Reclamo de Gastos Médicos (Planes de MEC/ESC 5500)

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.)

Prescription Drug Reimbursement Claim Form (MEC)

Wellness and Preventive Reimbursement Claim Form

 

Limited Benefits Forms

Dental Claim Form

EyeMed Out-of-Network Claim Form

Indemnity Plan Missed Premium Direct Payment Form

MEC Plan Missed Contribution Direct Payment Form

Short-Term Disability/Proof of Loss Form

Term Life / Accidental Loss of Life 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