All the information you need, in one place

You can get the information and care that you need quickly with these commonly-requested forms.

Share your health information with loved ones

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

DOWNLOAD (PDF, 118KB) ➜

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.

DOWNLOAD (PDF, 145KB) ➜

Member grievance / appeal form

Let us know if you're having any problems with your current plan or plan provider so we can help. Here's how to file a formal complaint or appeal.

GO TO GRIEVANCE FORM ➜

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.

MORE ABOUT CONTINUITY OF CARE ➜

Not finding what you’re looking for?

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