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.
Authorized Representative Form / Formulario de Representante Autorizado
Medical Claim Form (Indemnity) / Formulario de Reclamo de Gastos Médicos (Indemnity)
Medical Claim Form (MEC/MVP) / Formulario de Reclamo de Gastos Médicos (MEC/MVP)
Prescription Drug Claim Form (Use this form if Rx group ECPAI is on your ID card.) / Formulario de Reclamo de Recetas Médicas (Utilice este formulario si el grupo Rx ECPAI está en su tarjeta de identificación.)
Prescription Drug Claim Form (Use this form if Rx group ECFDRX is on your ID card.)
Prescription Drug Reimbursement Claim Form (MEC)
Accidental Loss of Limb or Sight Claim Form
Accidental Loss of Limb or Sight Claim Form-Attending Physician Statement
Dental Claim Form
EyeMed Out-of-Network Claim Form
Missed Premium Direct Payment Form / Formulario Para el Pago Directo de Primas no Cubiertas
Term Life or Accidental Death Claim Form
HIPAA-all groups