Helpful Forms

Use this form to submit a medical claim that you or your doctor did not submit to the insurance company.

Click here to download, view and print form.

A list of all preventive services that are covered at 100% with In-Network doctors.

Click here to download, view and print form.

Treatments and Procedures that are not covered under the health plan.

Click here to download, view and print form.

Summary of all medical benefits.

Click here to download, view and print form.

Mandatory Legal notice for all health plans.

Click here to download, view and print form.

Use this form to record your biometrics with your provider.

Click here to download, view and print form.

Use this form to be reimbursed if you paid out of pocket for a prescription and didn’t use your insurance.

Click here to download, view and print form.

Mandatory Legal notice for all health plans.

Click here to download, view and print form.

Beneficiary Designation Request

Click here to download, view and print form.

Adobe PDF Files

Adobe-Reader

All forms are in PDF file format.

To read and print a PDF file, you must have Adobe® Acrobat® Reader installed on your PC. You can download a version suitable for your system, free of charge, from Adobe.

Adobe also provides tools and information to help make Adobe PDF files accessible to users with visual disabilities at http://access.adobe.com.

Click here to download Acrobat Reader if the forms do not load correctly.

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