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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 ➜

Smoking cessation reimbursement form

Members who participate and complete a smoking cessation class or program will be reimbursed up to $100 per class or program per calendar year. Download the form below for more information.

DOWNLOAD (PDF, 20KB) ➜

Not finding what you’re looking for?

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