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.
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
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
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