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Access all the forms you need to help guide you on your health care journey with us.

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Authorization forms

To release or disclose information among designated individuals.

You’ll want to fill out the Member authorization to release PHI form (pdf). This form allows you to authorize Harvard Pilgrim to release/disclose certain protected health information (PHI), according to the terms you specify.

You’ll want to fill out the Confidential Exchange of Information form (pdf). This form allows behavioral health practitioners involved in your care to release health information to other health providers, according to the terms you specify.  

You’ll want to fill out the Designation of Representative form. This form allows you to authorize an individual to discuss and make decisions related to your health care and coverage.

You may need assistance from your provider to complete this form.

Complete online

Complete the paper form

In order to verify your dependent’s eligibility as a disabled adult — which includes authorization to obtain protected health information— you’ll need to fill out the Disabled Adult Dependent Verification form (pdf).

You may need assistance from your provider to complete this form.

To allow 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, a Statement of Parental Rights form (pdf) will need to be completed.

This form must be notarized by a Notary Public. You may need assistance from your provider to complete this form.

Medicare plan forms

Forms for Medicare Advantage and Medicare Supplement Plan members

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

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

Claims (request for reimbursement) forms

To claim reimbursement for covered behavioral health services received out of network, you’ll want to fill out the Behavioral Health Claim form.

You may need assistance from your provider to complete this form.

Complete Online

Complete the paper form (pdf)

To claim reimbursement for qualifying childbirth classes covered under your plan, you’ll want to fill out the Childbirth Class Reimbursement form (pdf)

To claim reimbursement for your child’s covered dental care received outside the dental network, you’ll want to fill out the Pediatric Dental Claim form (pdf).

To claim reimbursement for an approved health club or fitness facility membership that you have paid for out of pocket, you’ll want to fill out the Fitness Reimbursement form.

Complete Online

Complete the paper form (pdf)

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), you’ll want to fill out the Complementary and Alternative Medicine Reimbursement form. 

Complete Online

Complete the paper 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), you’ll want to fill out the Weight Management Reimbursement form.

Complete Online

Complete the paper form (pdf)

To claim reimbursement for medical and hospital services covered under your plan that you have paid for out of pocket, you’ll want to fill out the Medical Reimbursement form.  For prescription medications, be sure to use the Prescription Drug Reimbursement Claim form (pdf).

You may need assistance from your provider to complete this form.

Complete online

Complete the paper 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, you’ll want to complete the Prescription Drug Reimbursement Claim form (pdf).

Other insurance coverage forms

To coordinate medical or dental benefits for members covered by another health, dental or Medicare insurance plan, you’ll want to complete the Coordination of Benefits questionnaire.

Complete Online

Complete the paper form (pdf)

To ensure that a claim for an injury or illness resulting from an accident, such as a slip and fall, is processed correctly, simply complete the Insurance, Liability and Recovery questionnaire.

Complete Online

Complete the paper form (pdf)

Service request forms

Authorization forms

You’ll want to fill out the Member authorization to release PHI form (pdf). This form allows you to authorize Harvard Pilgrim to release/disclose certain protected health information (PHI), according to the terms you specify.

You’ll want to fill out the Confidential Exchange of Information form (pdf). This form allows behavioral health practitioners involved in your care to release health information to other health providers, according to the terms you specify.  

You’ll want to fill out the Designation of Representative form. This form allows you to authorize an individual to discuss and make decisions related to your health care and coverage.

You may need assistance from your provider to complete this form.

Complete online

Complete the paper form

In order to verify your dependent’s eligibility as a disabled adult — which includes authorization to obtain protected health information— you’ll need to fill out the Disabled Adult Dependent Verification form (pdf).

You may need assistance from your provider to complete this form.

To allow 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, a Statement of Parental Rights form (pdf) will need to be completed.

This form must be notarized by a Notary Public. You may need assistance from your provider to complete this form.

Medicare plan forms

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

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

Claims (request for reimbursement) forms

To claim reimbursement for covered behavioral health services received out of network, you’ll want to fill out the Behavioral Health Claim form.

You may need assistance from your provider to complete this form.

Complete Online

Complete the paper form (pdf)

To claim reimbursement for qualifying childbirth classes covered under your plan, you’ll want to fill out the Childbirth Class Reimbursement form (pdf)

To claim reimbursement for your child’s covered dental care received outside the dental network, you’ll want to fill out the Pediatric Dental Claim form (pdf).

To claim reimbursement for an approved health club or fitness facility membership that you have paid for out of pocket, you’ll want to fill out the Fitness Reimbursement form.

Complete Online

Complete the paper form (pdf)

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), you’ll want to fill out the Complementary and Alternative Medicine Reimbursement form. 

Complete Online

Complete the paper 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), you’ll want to fill out the Weight Management Reimbursement form.

Complete Online

Complete the paper form (pdf)

To claim reimbursement for medical and hospital services covered under your plan that you have paid for out of pocket, you’ll want to fill out the Medical Reimbursement form.  For prescription medications, be sure to use the Prescription Drug Reimbursement Claim form (pdf).

You may need assistance from your provider to complete this form.

Complete online

Complete the paper 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, you’ll want to complete the Prescription Drug Reimbursement Claim form (pdf).

Other insurance coverage forms

To coordinate medical or dental benefits for members covered by another health, dental or Medicare insurance plan, you’ll want to complete the Coordination of Benefits questionnaire.

Complete Online

Complete the paper form (pdf)

To ensure that a claim for an injury or illness resulting from an accident, such as a slip and fall, is processed correctly, simply complete the Insurance, Liability and Recovery questionnaire.

Complete Online

Complete the paper form (pdf)

Service request forms

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