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.

• Grievance and Appeals Form (coming soon): 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.
• Fraud, Waste and Abuse Reporting Form: Use this form if you think a member or provider is taking part in fraud, waste, or abuse.
• Navigate Member Claims Form
• 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.
• Member Exception Request: Use this form to ask for a medication exemption.
• Tell Us: Use this form to send us a question. You can also make a complaint, file an appeal, or tell us if you have other insurance.