All the information you need, in one place

Get the information and care that you need with these commonly requested forms.

Share your information with loved ones

At some point during your care, you may want us to disclose your protected health information (PHI) to someone else, like a partner or child. Here you’ll find the information you’ll need to authorize the release of health information.


Get reimbursed for medical services

If you're looking to be reimbursed for eligible out-of-pocket medical expenses, be sure to submit this reimbursement request form within 180 days of the date of service.


Get reimbursed for at-home COVID tests

Members can submit FDA approved at-home over-the-counter COVID-19 diagnostic tests for reimbursement beginning January 15, 2022. 


Member grievance / appeal form

Members who disagree with a utilization review decision or are dissatisfied with the care they have received, have the right to file a grievance or appeal. Provide members with this form to start the process.


Request continuity of care benefits

Continuity of care means continued services, under certain conditions, with your current health care provider until your provider completes your care. Find out if you qualify and learn how to submit a request by visiting the webpage.


Not finding what you’re looking for?

Let’s talk. Call us at 1-855-995-5004 or send us a message.