Member Forms

Need a form quickly?  You can easily find it here, alphabetized by general category (Authorizations, Claims, or Service Requests).   If you don’t see what you need, just call Member Services at (888) 333-4742 and we’ll help you find it.

Are you a Medicare Advantage or Medicare Supplement Plan member?  Find your forms here:

 

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. 

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.
 

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.

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.