Forms & Resources

At Health Plans, we take our commitment to your health very seriously. That’s why we want to be a key source of tools and information to help you be the healthiest you you can be.

Would you like to:

Print a form?

Order an ID Card?

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.