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.
 

  • Fitness Reimbursement Form (pdf)
    To claim reimbursement for an approved health club or fitness facility membership that you have paid for out-of-pocket.
     
  • 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 (pdf)
    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.
     
  • Weight Management Reimbursement Form (pdf)
    To claim reimbursement for an approved weight management program that you have paid for out-of-pocket if your plan includes this reimbursement benefit.

Other Insurance Coverage Forms

For HMO, POS & PPO plans, these forms are required if you have health coverage – including Medicare – through other insurers (in addition to your Harvard Pilgrim insurance);  and/or if your claim is for an injury or illness resulting from an accident (such as a slip & fall.)
 

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.