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 (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)

Limited Benefits Forms

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

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