Forms
Listed below are forms you may need. Forms may be downloaded for printing.
- Tell Us – When you would like to send us a question.
- Grievance/Appeal Form – When you have a complaint about a service or would like to dispute a decision.
- Prescription Reimbursement Claim Form
- Fraud, Waste and Abuse Reporting Form – When you have a complaint about a service or would like to dispute a decision. Vist Fraud, Waste, & Abuse page.
- Member Consent/HIPAA Authorization Form –You agree to share your health information with your providers and/or to someone you name. Or, fill out this hard-copy version Please allow up to 30 days to process.
- IRS 1095B Form
- Frequently Asked Questions about the 1095B Tax Form
- Club Membership Form
Member Services: 1-855-202-0729 (TTY: 1-800-255-0056 or 711), Monday – Friday 7 a.m. – 7 p.m.