Authorization Forms

Use these forms to authorize the release or disclosure of information among designated individuals and caregivers for a specific purpose or time period. 

• Authorization to Release Information Form (pdf)
  To authorize Harvard Pilgrim to release/disclose certain health information according to the terms you specify. 
   
• Confidential Exchange of Information Form (pdf)
  To allow behavioral health practitioners involved in your care to release health information to other health providers according to the terms you specify.   
   
• Designation of Representative Form (pdf)
  To authorize an individual to discuss and make decisions related to your health care and coverage.
   
• Disabled Adult Dependent Verification Form (pdf)
  To verify your dependent's eligibility as a disabled adult; includes Authorization to Obtain Protected Health Information.
   
• Parental Rights Statement Form (pdf)
  To allow Harvard Pilgrim representatives to speak to a parent about the health coverage and care of their dependent (under age 18) when the parent is not listed on that minor’s policy.  Must be notarized.

Claims (request for reimbursement) Forms

Use these forms to request reimbursement or payment for services covered by your plan. Restrictions may apply, so please be sure to  follow the form instructions carefully and refer to My Plan Documents as needed.
 

• Behavioral Health Claim Form (pdf)
  To claim reimbursement for covered Behavioral Health services received out-of-network.
   
• Childbirth Class Reimbursement Form (pdf)
  To claim reimbursement for qualifying childbirth classes covered under your plan. 
   
• Pediatric Dental Claim Form (pdf)
  To claim reimbursement for covered dental care received outside the dental network.
   
• Fitness Reimbursement
  To claim reimbursement for an approved health club or fitness facility membership that you have paid for out-of-pocket.
  
  Online Fitness Reimbursement From (login required) 
  Fitness Reimbursement Form (pdf)
   
• Complementary and Alternative Medicine Reimbursement 
  To claim reimbursement for approved complementary and alternative medicine services that you have paid for out-of-pocket if your plan includes this reimbursement benefit. 
  
  Complementary and Alternative Medicine Reimbursement Form (login required) 
  Mailed Complementary and Alternative Medicine Reimbursement Form (pdf)
   
• Weight Management Reimbursement 
  To claim reimbursement for an approved weight management program that you have paid for out-of-pocket if your plan includes this reimbursement benefit.
  
  Weight Management Reimbursement Form (login required)
  Weight Management Reimbursement Form (pdf)
   
• Online Medical Claim Form (login required)
  To claim reimbursement for medical and hospital services covered under your plan that you have paid for out-of-pocket.  (For prescription medications, be sure to use the Prescription Drug Reimbursement Claim Form below.)
   
• Medical Reimbursement Form (pdf)
  To claim reimbursement for medical and hospital services covered under your plan that you have paid for out-of-pocket. 
   
• Prescription Drug Reimbursement Claim Form
  For HMO, POS and PPO Plans, to claim reimbursement for prescription medications covered under your plan that you have paid for out-of-pocket.
   
• Access America Claim Form (pdf)
  To claim reimbursement—or to authorize payment to the provider—for medical and hospital services covered under your Access America plan.
   
• International Claim Form (pdf)
  To claim reimbursement for medical and hospital services received outside the U.S. that are covered under your plan.

Other Insurance Coverage Forms

Vision Care Claim Forms

To claim reimbursement for prescription eyeglasses and frames or prescription contact lenses covered under your plan that you have paid for out-of-pocket.

• Adult Vision Care Reimbursement Form (pdf)
• Pediatric Vision Claim Form - CT (pdf)
• Pediatric Vision Claim Form - MA (pdf)
• Pediatric Vision Claim Form - Maine (pdf)
• Pediatric Vision Claim Form - NH (pdf)

Service Request Forms

Use these forms to request a new service, such as an electronic funds transfer or mail service for delivery of prescription drugs.

• Electronic Funds Transfer Form
  To authorize automatic premium payments from your checking account. 
   
• Medication Mail Order Form
  To receive approved medicines by mail from MedImpact Direct according to your plan’s coverage.