Forms
- Beneficiary Claim Form
- DisposeRx® Request Form: Get a free DisposeRx packet to help you dispose of unused or expired medications.
- Fraud, Waste and Abuse Reporting Form: Use this form if you think that a beneficiary, provider, or pharmacy is taking part in fraud, waste, abuse or overpayment.
- Grievance and Appeals Form (coming soon): Use this form if you have a complaint about a service you received or do not agree with a decision we made.
- HIPAA Authorization Form: Use this form to share your health information with your providers or someone else:
- Fill out the form online.
- Print the form.
- Member Consent Authorized Rep HIPAA Form
- Interpreter Services Brochure
- Interpreter Service Request Form
- Statement of Personal Injury - Possible Third Party Liability (DD Form 2527)
- Tell Us (coming soon): Use this form when you would like to send us a question. You can also make a complaint, file an appeal or tell us if you have any other insurance.