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 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)
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-Attending Physician Statement
Dental Claim Form / Formulario de reclamo dental
EyeMed Out-of-Network Claim Form
Missed Premium Direct Payment Form / Formulario Para el Pago Directo de Primas no Cubiertas
Short-Term Disability - Proof of Loss Claim Form / Formulario de discapacidad a corto plazo - prueba de pérdida
Term Life or Accidental Death 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