HPI | Volusia Health Network | Health Plans Inc. | Employers

We are committed to keeping you up-to-date on all aspects of your benefit plan. Whether you need to request a new ID card for an employee or download an important form, you can find it all here.

Would you like to:

Download the Administrative Guide

Print a form for yourself

Print a form for a member

Order an ID Card or print a temporary card for a member

Forms for Employers

Authorization

Employer Portal Access Form

COBRA Enrollment

COBRA Qualifying Event Termination

Forms for Members

Authorizations & Verifications

Online Access / PHI Disclosure Form

Member Authorization to Obtain PHI

Member Authorization to Release PHI - Care Management Services

Member Authorization to Release PHI - Claims

Transition of Care Request Form

Member Appeal

Member Appeal Form

Request for Network Exception

Network Exception Request Form

Member Reimbursements

Standard Medical Claim Form

Standard Dental Claim Form

Member Reimbursement Form submit your request in My Plan

Travel Reimbursement Form submit your request in My Plan

Verifications

Out-of-Area Dependent Coverage Verification Form

*Claim and reimbursement forms may not be applicable to all plans. Be sure to check your benefit details in your summary plan description prior to submitting a claim or reimbursement form.

Some forms on this page are in PDF format and require Adobe Reader to open.