Forms
How to View and Download
To view or download a file, select the desired language link. The PDF file will open in a new window or tab of your browser. From there, you can also download or print the file.
Medical Claim Form for Group and Individual & Family Plans
Medicare – Medical – MHN Claim Form & Foreign Claim Questionnaire
Non-Medicare – Behavioral Health (MHN) – Claim Form
Commercial Grievance Form
Hardship Exemption Form
Continuity of Care Assistance Request Form
- Continuity of Care Assistance Request Form – English (PDF)
- Continuity of Care Assistance Request Form – En Español (Spanish) (PDF)
Disabled Dependent Certification Form
CVS Caremark Mail Order Pharmacy
- CVS Caremark Mail Order Pharmacy – English (PDF)
- CVS Caremark Mail Order Pharmacy – En Español (Spanish) (PDF)
Prescription Drug Claim Form (Medicare Members)
- Prescription Drug Claim Form (Medicare Members) – English (PDF)
- Prescription Drug Claim Form (Medicare Members) – En Español (Spanish) (PDF)
Prescription Drug Claim Form (Commercial Members)
- Prescription Drug Claim Form (Commercial Members) – English (PDF)
- Prescription Drug Claim Form (Commercial Members) – En Español (Spanish) (PDF)
Prescription Transition Form (Commercial Members)
Glossary of Health Coverage and Medical Terms
- Glossary of Health Coverage and Medical Terms - English (PDF)
- Glossary of Health Coverage and Medical Terms - En Español (Spanish) (PDF)
- Glossary of Health Coverage and Medical Terms - Chinese Mandarin - 中文 (PDF)
- Glossary of Health Coverage and Medical Terms - Navajo - Diné bizaad (PDF)
- Glossary of Health Coverage and Medical Terms - Korean - 한국어 (PDF)
Health insurance companies and group health plans are required to make available a uniform glossary of health coverage and medical terms commonly used in plan documents. The Uniform Glossary is meant to help the consumer understand some of the most common language used in health insurance documents. Please log in to request a hardcopy of the document by mail.