Forms

Medical Claim

Use this Medical Claim form for reimbursement of covered medical expenses.

Global Core International Claim

Use this Global Core International Claim form to submit institutional and professional claims for covered services received outside the United States, Puerto Rico and the U.S. Virgin Islands.

Coordination of Benefits

Use this Coordination of benefits form if you or a family member has other health insurance covering you and/or your dependents.

Service Availability

Use this Service Availability form if you need medical care that is not currently available in your PPO network.

Dental Claim

Use this Dental Claim form for reimbursement of covered dental expenses.

Privacy Forms

Use this HIPAA - Authorization Form for Information Release to share your health information with a third party such as a family member, employer, lawyer, broker or unrelated party by completing and submitting this authorization.

Use this HIPAA - Access Request Form to make a one-time request to inspect and/or obtain copies of your protected health information maintained by your insurer as allowed law.

Use this HIPAA - Accounting of Disclosure Request Form to make a request for an accounting of disclosures of your protected health information maintained by your insurer or its Business Associates.

Use this HIPAA - Amendment Request Form to make a request to amend your protected health information created and maintained by your insurer or its Business Associates.

Use this HIPAA - Designation of Personal Representative to designate a personal representative who will act on your behalf in making decisions related to health care, which includes treatment and payment issues. This individual can be a family member, friend, lawyer, or unrelated party.

Use this HIPAA - Restriction Request Form to request that your insurer restrict the use and disclosure of the protected health information for treatment, payment, or health operations. Do not use this form to request a confidential communication or alternate address.

Use this HIPAA - Restriction Termination Request Form to make a request that your insurer terminate a restriction previously requested and agreed upon.

Use this HIPAA - Revocation of Authorization or Designation of Personal Representative Form to revoke an authorization or personal representative designation.