Forms
Instructions are included on each form. They will tell you where you need to return it if it is not an online form. The form will also tell you who to call if you have questions. Call Member Services to get a printed copy sent to you.
Tell Us:
Use this form to send us a question. You can also make a complaint, file an appeal, report a new address or phone number, or tell us if you have other insurance.
Member Consent/HIPAA Authorization Form:
Share your health information with your providers or someone else. Or, you can fill out this
hard-copy version to send to us:
Privacy Office
P.O. Box 8738
Dayton, OH 45401-8738
Fraud, Waste and Abuse Reporting Form:
Use this form if you think a member or provider is taking part in fraud, waste, or abuse.
Grievance and Appeals Form:
Use this form if you have a complaint about a service or care you got from a provider. You can also fill this out if you do not agree with a decision we made.
Member Claim Form:
Fill this out to ask to be reimbursed for services you paid for. You may get reimbursed if the services should have been paid for by .
Member Exception Request:
Use this form to ask for an exception for a medication not on the PDL.
Prescription Reimbursement Claim Form:
Fill this out to ask for a reimbursement for a prescription drug you paid for.
Other Forms
- Non-Opioid Directive form (English | Spanish | Arabic)
- Meals and Lodging Reimbursement Form
Member Services: 1-833-230-2053 (TTY: 711), 24 hours a day, seven days a week.