Medicare Supplement Plan Forms
Accident/Injury Questionnaire Form
To claim is for an injury or illness resulting from an accident (such as a slip & fall.)
Additional Health Insurance Coverage Form (pdf)
To coordinate medical/dental benefits for its members who are covered by any other health, dental and/or Medicare insurance.
Authorization to Release Information Form (pdf)
To authorize Harvard Pilgrim to release/disclose certain health information according to the terms you specify.
Behavioral Health Claim Form (pdf)
To claim reimbursement for covered Behavioral Health services received out-of-network.
Designation of Representative Form (pdf)
To authorize an individual to discuss and make decisions related to your health care and coverage.
Fitness Reimbursement Form (pdf)
To claim reimbursement for an approved health club or fitness facility membership that you have paid for out-of-pocket.
Medical Reimbursement Form (pdf)
To claim reimbursement for medical and hospital services covered under your plan that you have paid for out-of-pocket.