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Medical Claim Form for Group and Individual & Family Plans

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

Complete the claim form for each member submitting bills for reimbursement of covered services. To avoid any delay, be sure to answer each question completely. PLEASE ATTACH FULLY ITEMIZED BILLS AND PROOF OF PAYMENT.

Proof of payment includes:

• Copy of cancelled check (front and back) or online bank statement
• Copy of credit card statement or bank statement

NOTE:

• Proof of payment on a Dr.'s prescription form is not acceptable.
• Invoices are not acceptable forms of proof of payment.

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)

IFP and Group Member Grievance Form

• Grievance Form – English (PDF)
• Grievance Form – Chinese Mandarin – 中文 (PDF)
• Grievance Form – En Español (Spanish) (PDF)

Please explain in detail the circumstances that led to your dissatisfaction with Health Net. Please include the original copy of any claims or bills received which are related to your issue.

Dental Claim Form

• Dental Claim Form – English (PDF)

Medicare Supplement Plan Claim Form

• Medicare Supplement Plan Claim Form – English (PDF)

Out-of-Network Vision Claim Form (non-Medicare)

• Out-of-Network Vision Claim Form – English (PDF)

Hardship Exemption Form

• Hardship Exemption Form – English (PDF)

HSA for Life - Enrollment Packet

• HSA for Life - Enrollment Packet – English (PDF)

For enrolling in a Health Savings Account (HSA)

First Health Provider Nomination Form

• First Health Provider Nomination Form – English (PDF)

You can save a lot by using a doctor who participates in the First Health Network. That's why we make it easy for you to nominate him or her to join.

Continuity of Care Assistance Request Form

• Continuity of Care Assistance Request Form – English (PDF)
• Continuity of Care Assistance Request Form – En Español (Spanish) (PDF)

Health Net Life Group Employee/Dependent Enrollment Form

• Employee/Dependent Enrollment Form – English (PDF)
• Employee/Dependent Enrollment Form – En Español (Spanish) (PDF)
• Employee/Dependent Enrollment Form – Chinese Mandarin – 中文 (PDF)

Disabled Dependent Certification Form

• Disabled Dependent Certification Form – English (PDF)

Out-of-Pocket Maximum Notification

• Out-of-Pocket Maximum Notification – English (PDF)

Large Group Enrollment/Change Form

• Large Group Enrollment/Change Form – English (PDF)
• Large Group Enrollment/Change Form – En Español (Spanish) (PDF)
• Large Group Enrollment/Change Form – Chinese Mandarin – 中文 (PDF)

Small Business Group Employee Enrollment and Change Form (January 2016)

• Small Business Group Employee Enrollment and Change Form – English (PDF)
• Small Business Group Employee Enrollment and Change Form – En Español (Spanish) (PDF)
• Small Business Group Employee Enrollment and Change Form – Chinese Mandarin – 中文 (PDF)
• Small Business Group Employee Enrollment and Change Form – Korean – 한국어 (PDF)

Must be completed and submitted at time of enrollment in order to enroll new employees and existing dependents. Also used for employees and dependents waiving coverage.

Mail Order Pharmacy

CVS Caremark Mail Order Pharmacy

• CVS Caremark Mail Order Pharmacy – English (PDF)
• CVS Caremark Mail Order Pharmacy – Spanish – Español (PDF)

Prescription Claims

Prescription Drug Claim Form (Medicare Members)

• Prescription Drug Claim Form (Medicare Members) – English (PDF)
• Prescription Drug Claim Form (Medicare Members) – Spanish – Español (PDF)

Prescription Drug Claim Form (Commercial Members)

• Prescription Drug Claim Form (Commercial Members) – English (PDF)
• Prescription Drug Claim Form (Commercial Members) – Spanish – Español (PDF)

Prescription Transition Form

Prescription Transition Form (Commercial Members)

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