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Commonly Used Forms
Commonly Used Member Forms
These forms are in Adobe Acrobat (.pdf) format. Get the Acrobat reader here.
- Member/Subscriber Claim Form
- Member/Subscriber Claim Form (For Medicare Only)
- HIPAA - General Release of Information Form: Member/Subscriber
- Advance Directives Form
- Injury Questionnaire Form
- Level 1 Appeal Form
- Grievance Form
- Transition of Care Services Form
Individual Health Plan: Member Plan Change Forms
- Termination: When you need to terminate your Individual Plan coverage or a dependant from your plan.
Individual Plan Voluntary Member Termination Form
- Add or Move a Dependant: When you are requesting to add or move a dependant to or from your current benefits.
Individual Plan Member Add Dependent Form and Medical Form
- Health Savings Account Authorization Form: For Savvy100 members only.
Individual Health Plan: Member Reimbursement Forms
For Individual PresMetro, PresSolo, and Select members requesting reimbursement for eligible services such as alternate therapies, dental treatment or diagnostic devices, please select the appropriate form below.
- PresSolo Plan: PresSolo Unique Services Reimbursement Form
- Select Plan: Select Plan Unique Services Reimbursement Form
- PresMetro Plan: PresMetro Unique Services Reimbursement Form
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