Washington Member Forms and Materials

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 team.

Forms

Administer Your Coverage

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
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

Claims and Medical Benefit Forms

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

Plan Benefits and Information

Medical

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
Provider Directory - Online  
Selecting a Primary Care Provider (PCP) en Español
Travel: Access Care Nationally en Español
Travel: Benefits While Traveling Abroad
Value-added Extras en Español

Health and Wellness Programs and Information

Health Condition Management Information

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

Wellness Programs

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

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.

 

InTouch for Members

Last updated 1/17/2020