Forms

Medical Claim Form for Group and Individual & Family Plans

• Medical Claim Form – English (PDF)
• Medical Claim Form – En Español (Spanish) (PDF)

Medicare – Medical – MHN Claim Form & Foreign Claim Questionnaire

• MHN Claim Form & Foreign Claim Questionnaire – English (PDF)

Non-Medicare – Behavioral Health (MHN) – Claim Form

• Behavioral Health (MHN) – Claim Form – English (PDF)

Commercial Grievance Form

• Commercial GRIEVANCE FORM – English (PDF)
• Commercial GRIEVANCE FORM – En Español (Spanish) (PDF)
• Commercial GRIEVANCE FORM – Chinese (PDF)

Hardship Exemption Form

Hardship Exemption Form – English (PDF)

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

Disabled Dependent Certification Form – English (PDF)

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)

• Prescription Transition Form (Commercial Members) – English (PDF)
• Prescription Transition Form (Commercial Members) – En Español (Spanish) (PDF)

Authorization For Disclosure of PHI

• Authorization For Disclosure of PHI - English (PDF)
• Authorization For Disclosure of PHI - En Español (Spanish) (PDF)
• Authorization For Disclosure of PHI - Chinese Mandarin - 中文 (PDF)
• Authorization For Disclosure of PHI - Korean - 한국어 (PDF)

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.