Forms and Materials for Our Members

The forms and materials available on this page are not specific to any particular plan. If you have questions about your plan's coverage, please check your benefit materials, or contact our Customer Service Department.

Forms

Plan Benefits and Information

Health and Wellness Programs

Online Tools

CaféWell: Personalized Guidance for a Healthier Life
InTouch: Access Your Plan Info from Your Computer, Tablet, or Phone
Payment Options
Provider Directory - Online

Medicare

Visit our Medicare Website to find Medicare forms.

Medicaid

Visit our Medicaid Website to find Medicaid forms.

InTouch for Members

How to Submit a Claim

In most cases, your provider will submit your claim for you. If you need to submit a claim to us, please see our How to Submit a Claim member flier for details.

Authorization to Use or Disclose PHI	en Español
Confidential Communication (Parent/Guardian Information) Form
Coordination of Benefits Form
Designation of Authorized Representative
Electronic Funds Transfer (EFT) Authorization	en Español
Employee Address or Name Change	en Español
Individual Policy Change Form
Request Accounting of Disclosures
Request Record Set Access
Request to Amend a Designated Record Set
Restrict Record Set Access

Accident Report (Medical Service Questionnaire)
Appeal Form
Care Coordination Request
Claim Form - Dental
Health Claim Reimbursement Request Form
Prescription Drug Claim Form

Advantage Dental
BrightPath
First Health Network
IPN
PacificSource (PSN), SmartHealth, and SmartChoice Networks

Diabetes Benefits	en Español
Health Insurance: Know the Lingo
How to Submit a Claim
Mail Order Pharmacy Options	en Español
Making Sense of Third Party Recovery	en Español
Member Guide	en Español
Preauthorization
Prescription Discount Program for Plans with Pharmacy Endorsement
Prescription Discount Program for Plans without Pharmacy Endorsement
Selecting a Primary Care Provider (PCP)	en Español
SmartChoice: Using Your Plan
Travel: Access to Care Nationwide	en Español
Travel: Benefits While Traveling Abroad
Value-added Extras	en Español

Dental: How to Maximize Your Dental Benefits	en Español
How a Healthy Mouth Can Help Your Whole Body
Member Guide (for members with dental-only plans)

24-Hour NurseLine	en Español
ABCs of Carb Counting	en Español
Condition Support to Help You Live Well	en Español
Diabetes Sick Day Plan	en Español
Doctor Visit Guide
Encouraging Your Child to Self-manage Diabetes	en Español
Global Emergency Services Tri-fold Brochure
Health and Wellness Journey Map
Juvenile Diabetes Management Program	en Español
Mouth-Body Connection
Understanding and Overcoming Depression
Understanding the 15:15 Rule	en Español
What's My Target A1c?	en Español

Active&Fit Direct - Gym Membership Program	en Español
Health Education Classes	en Español
Jenny Craig
Prenatal Program	en Español
Teladoc: Healthcare via phone, video, or mobile app	en Español
Tobacco Cessation: Quit For Life Program	en Español
Weight Watchers Program	en Español

Forms and Materials for Our Members

Forms

Administer Your Coverage

Claims and Medical Benefit Forms

Provider Nomination Forms

Plan Benefits and Information

Medical

Dental

Health and Wellness Programs

Health Condition Management Information

Wellness Programs

Online Tools

Medicare

Medicaid

InTouch for Members

How to Submit a Claim

Our Company

Our Plans

Members

Employers

Agents

Providers

Language Help