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Request reimbursement for an in-person childbirth class or Tinyhood's online program.This reimbursement program is not available to all Harvard Pilgrim members. You can <a href="https://www.harvardpilgrim.org/hphconnect/secure/connectj2ee/jsp/secure/member/fitnessSelfServiceServlet/reimbursementLandingPage.htm" target="_blank">check your eligibility</a> through your secure member account.

Childbirth class reimbursement form

Request reimbursement for approved complementary and alternative medicine services that you paid for out of pocket (if your plan includes this reimbursement benefit).<a class="btn btn-secondary" href="https://www.harvardpilgrim.org/hphconnect/secure/connectj2ee/jsp/secure/member/fitnessSelfServiceServlet/?systemName=AM" target="_blank">Complete this form online</a>

Complementary and alternative medicine reimbursement form

Authorize behavioral health practitioners involved in your care to release health information to other providers, according to the terms you specify.&nbsp;&nbsp;

Confidential exchange of information form

Get help coordinating medical or dental benefits for members covered by another health, dental or Medicare insurance plan.<a class="btn btn-primary btn-secondary" href="https://www.harvardpilgrim.org/member/cob" target="_blank">Complete this form online</a>

Coordination of benefits questionnaire

Authorize someone to act as your health care representative and discuss and make decisions related to your health care and coverage.You may need assistance from your provider to complete this form.<a class="btn btn-secondary" href="https://www.harvardpilgrim.org/member/dor" target="_blank">Complete this form online</a>

Designation of representative form

Authorize Harvard Pilgrim to release/disclose health information for a disabled adult dependent and verify their eligibility.You may need assistance from your provider to complete this form.

Disabled adult dependent verification form

Request reimbursement for fees you pay toward a fitness facility, virtual fitness class subscription or other qualified membership.This reimbursement program is not available to all Harvard Pilgrim members. You can <a href="https://www.harvardpilgrim.org/hphconnect/secure/connectj2ee/jsp/secure/member/fitnessSelfServiceServlet/reimbursementLandingPage.htm" target="_blank">check your eligibility</a> through your secure member account.<a class="btn btn-primary btn-secondary" href="https://www.harvardpilgrim.org/hphconnect/secure/connectj2ee/jsp/secure/member/fitnessSelfServiceServlet/" target="_blank">Complete this form online</a>

Fitness reimbursement form

Request reimbursement for out-of-pocket costs that you paid for covered medical, hospital and behavioral health services.&nbsp;Use the&nbsp;<a href="/media/1666" target="_blank" data-entity-type="media" data-entity-uuid="df4fdf18-edfb-480a-8895-990a566afeeb" data-entity-substitution="canonical">Prescription drug reimbursement claim form (pdf)</a> to request reimbursement for out-of-pocket costs that you paid for covered prescription medications.You may need assistance from your provider to complete this form.<a class="btn btn-secondary" href="https://hphconnect.harvardpilgrim.org/asp/healthbank/harvardpilgrim/secure/Member/MemberReimbursement.asp?_gl=1*1vevdlr*_ga*ODE2MzkxMDkwLjE3MjcxOTk5ODM.*_ga_3NSY6WSSS1*MTc0MzYwOTU0MC40MTIuMS4xNzQzNjEyMjI1LjU3LjAuMA..*_gcl_au*MTUxMzkzNDk3NC4xNzM4OTQxNjUx*_ga_ENB141VWJZ*MTc0MzYwOTU0MC4xNDMuMS4xNzQzNjE1MzE2LjU4LjAuMA.." target="_blank">Complete this form online</a>

Health care reimbursement claim form

Ensure that a claim for an injury or illness resulting from an accident, such as a slip and fall, is processed correctly.<a class="btn btn-primary btn-secondary" href="https://www.harvardpilgrim.org/member/ilr" target="_blank">Complete this form online</a>

Insurance, liability and recovery questionnaire

Request prior authorization for a prescription (Massachusetts providers only).

Massachusetts medication request form

Get all the Medicare Advantage Stride forms you need — enrollment, reimbursement, prescription drug, billing, representative designation, privacy and more.

Medicare Advantage Stride℠ forms

Get all the Medicare Supplement Plan forms you need — additional health insurance coverage, accident/injury questionnaire, authorizations, reimbursement, claim, representative designation and more.

Medicare Supplement Plan forms

Authorize Harvard Pilgrim to release/disclose certain protected health information (PHI), according to the terms you specify.

Member authorization to release PHI form

Request prior authorization for a prescription (New Hampshire providers only).

New Hampshire medication request form

Get 90-day supplies of maintenance medications by mail from OptumRx.

OptumRx home delivery order form

Request reimbursement for covered dental care your child received outside the dental network.

Pediatric dental claim form

Request documentation in Harvard Pilgrim’s system as a member's personal representative (e.g., health care proxy, power of attorney, etc.)

Personal representative cover form

Request reimbursement for prescription medications that you paid for out of pocket and are covered under your HMO, POS or PPO plan.

Prescription drug reimbursement claim form

Request prior authorization for a prescription (All other providers).

Standard medication request form

Authorize Harvard Pilgrim representatives to speak to a parent about the health coverage and care of their dependent (under age 18) when parent is not listed on that minor’s policy.

Statement of parental rights form

Request reimbursement for travel expenses primarily for and essential to covered services that are restricted or prohibited in your state of residence as a result of state law.

Travel benefit reimbursement form

Request reimbursement for fees you pay toward a qualified weight management program.This reimbursement program is not available to all Harvard Pilgrim members. You can <a href="https://www.harvardpilgrim.org/hphconnect/secure/connectj2ee/jsp/secure/member/fitnessSelfServiceServlet/reimbursementLandingPage.htm" target="_blank">check your eligibility</a> through your secure member account.<a class="btn btn-primary btn-secondary" href="https://www.harvardpilgrim.org/hphconnect/secure/connectj2ee/jsp/secure/member/fitnessSelfServiceServlet/?systemName=WW" target="_blank">Complete this form online</a>

Weight management reimbursement form

Request reimbursement for money you pay toward qualified nutrition programs, mindfulness apps, fitness equipment and more.This reimbursement program is not available to all Harvard Pilgrim members. You can <a href="https://www.harvardpilgrim.org/hphconnect/secure/connectj2ee/jsp/secure/member/fitnessSelfServiceServlet/reimbursementLandingPage.htm" target="_blank">check your eligibility</a> through your secure member account.<a class="btn btn-primary btn-secondary" href="https://www.harvardpilgrim.org/hphconnect/secure/connectj2ee/jsp/secure/member/fitnessSelfServiceServlet/?systemName=WR" target="_blank">Complete this form online</a>

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