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Member Forms

If you don't see the form you are looking for, please contact Member Services.
Forms for Medicare Supplement Plans

Claim/reimbursement forms: Purpose:
Behavioral Health Claim Form
POS & PPO Plan
Submit behavioral claims for out-of-network services.
Fitness Reimbursement Form Apply for health and fitness club reimbursement. Reimbursement requirements apply.

Medical Claim Form

Submit for reimbursement of a medical service when applicable.

Pediatric Dental Claim Form

To submit for reimbursement for covered dental care outside the dental network.

Pediatric Vision Claim Form
Maine

Pediatric Vision Claim form
NH

To submit for reimbursement for prescription eyeglasses and frames or prescription contact lenses that you have paid for.
Childbirth Class Reimbursement Form Apply for reimbursement for a childbirth education class. (For MA members with individual coverage, or coverage through an employer group with 50 or fewer employees. Check with your employer to see if you qualify.)
Weight Loss Program Reimbursement Form Apply for weight loss program reimbursement. (For MA members with individual coverage, or coverage through an employer group with 50 or fewer employees. Check with your employer to see if you qualify.)
International Claim Form Evaluate and administer claims for services that were received outside of the United States.
Prescription Drug Reimbursement Claim Form
HMO, POS & PPO Plan

Submit for reimbursement of a prescription drug, when applicable
Access America Claim Form Evaluate and administer claims for benefits for members with Access America Plans.

Coordination of Benefits Form
HMO, POS & PPO Plan

Determine if a member is covered by any other health insurance.
Motor Vehicle, Worker's Compensation, and Other Injury
HMO, POS & PPO Plan
Determine if a member is covered by other insurance as a result of an accident.

Member Authorization forms: Purpose:

Member Authorization to Release Information
HMO, POS & PPO Plan

Authorize Harvard Pilgrim to release (disclose) information to another individual for a specific purpose or time period. Appropriate for most situations, including naming an individual to help with a specific issue, incident or claim.

Designation of a Personal Representative
HMO, POS & PPO Plan

Appoint an individual to act as your representative to make decisions related to your Harvard Pilgrim health care and coverage. Appropriate for close relations; authorization is permanent unless revoked in writing.

Electronic Funds Transfer Enroll in the electronic banking program that allows you to pay your monthly premium payment without writing a check.
Parental Rights Statement Allows Harvard Pilgrim Representatives to speak to the parent of a dependent under 18 regarding the minor's health care and coverage as allowed by our Privacy Policies, when the parent is not on the policy. This form must be notarized.
Exercising your Privacy Rights Forms not available online.
To exercise your privacy rights, contact Member Services at 1-888-333-4742. If you are a member of a student resource plan, visit www.uhcsr.com

Eligibility: Purpose:
Student Verification

Form not available online. To verify your dependent student or to obtain an affidavit contact Member Services at 1-888-333-4742.

Disabled Adult Dependent Verify your dependent's eligibility as a disabled adult dependent.


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