Forms library.

Enrollment or change form

Add or remove a dependent, report a qualifying life event, or change plans during an enrollment period.

Address and contact update

Keep your mailing address, phone, email, and preferred language current so notices reach you.

Coordination of benefits questionnaire

Tells your plan whether anyone covered also has other coverage, which decides who pays first.

Disenrollment or termination request

Ends coverage for you or a dependent, with the effective date you specify.

Member claim reimbursement form

Submit a claim yourself when you paid a provider directly. Attach the itemized receipt showing the date, provider, service codes, and amount.

Out-of-network claim form

Used when the provider does not bill your plan. Ask the office for an itemized statement rather than a credit card slip.

Accident or injury questionnaire

Sent when a claim looks accident related, so the plan can tell whether another policy is responsible first. Claims stay pending until it is returned.

Overpayment or refund request

For getting money back when a bill was paid twice or paid before the claim was processed.

Prescription drug claim form

For reimbursement when you paid cash at the pharmacy, including fills while traveling.

Prior authorization request

Your prescriber sends this when a drug needs approval before the plan will cover it.

Formulary exception request

Asks the plan to cover a drug that is not on the list, or at a lower tier, when the covered alternatives are not appropriate for you.

Mail order and home delivery setup

Starts 90 day fills for maintenance medications through the plan pharmacy.

Appeal request form

Asks the plan to reconsider a denied claim or a denied authorization. File by the deadline printed in your denial letter.

Grievance form

For complaints about quality of care, access, or how you were treated, rather than about a payment decision.

External review request

Sends the decision to an independent reviewer after the plan upholds its own denial.

Expedited review request

Used when waiting for a standard decision could seriously jeopardize your health. Decisions come back in days, not weeks.

Authorization to release health information

Lets your plan share your information with a person or organization you name, for the purpose and period you set.

Personal or authorized representative form

Names someone who can speak to the plan and act on your behalf, such as a spouse, adult child, or caregiver.

Request for confidential communications

Asks the plan to send notices to a different address or by a different method when normal delivery would put you at risk.

Request for records or an accounting of disclosures

Asks for a copy of the information the plan holds about you, or a list of who it has been shared with.

Automatic payment authorization

Sets up recurring premium payments from a bank account or card, or changes the account already on file.

Premium payment dispute

For a premium that was charged twice, applied to the wrong month, or billed after coverage ended.

Tax form request

Requests a replacement copy of the coverage statement you use at tax time, such as a 1095 form.

Language or accessible format request

Asks for plan materials in another language, in large print, in braille, or in audio, at no cost to you.