Forms

Listed below are forms you may need. Some 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.
  • Navigate 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. Visit 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 Navigate hard-copy version Please allow up to 30 days to process.
  • IRS 1095B Form
  • Navigate Frequently Asked Questions about the 1095B Tax Form
  • Navigate Club Membership Form

Member Services: 1-855-202-0729 (TTY: 711), open Monday through Friday 7 a.m. to 7 p.m.