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Member Materials and Forms
Member Resources
Many of our member resources, such as the member handbook and forms, can be found by logging into your online member account. Click Login to create an account and access a wide array of resources!
Many of our member resources, such as the member handbook and forms, can be found on our secure portal. Click Login to create an account and access a wide array of resources! We’ve also provided a few resources below.
Member Handbook
Reference Materials
- Advance Directives
- Authorization to Disclose Health Information Form & Revocation of Authorization Form - English (PDF)
- Authorization to Disclose Health Information Form & Revocation of Authorization Form - Spanish (PDF)
- Authorization to Disclose Health Information Form & Revocation of Authorization Form - Chinese (PDF)
- Authorization to Disclose Health Information Form & Revocation of Authorization Form - Russian (PDF)
- Authorization to Disclose Health Information Form & Revocation of Authorization Form - Vietnamese (PDF)
- Doctor's Office Visit Checklist (PDF) - Use this checklist to get prepared for your next doctor's appointment.
- Find a Provider Guide (PDF)
- Get Your Flu Shot
- Helpful Links
- Grievance and Appeal Process (PDF)
- List of Covered Preventive Services
- Member Rights & Responsibilites (PDF)
- Notice of Privacy - English (PDF)
- Notice of Privacy - Spanish (PDF)
- Notice of Privacy - Chinese
- Notice of Privacy - Korean (PDF)
- Notice of Privacy - Russian (PDF)
- Notice of Privacy - Vietnamese (PDF)
- Preventive Services Guide (PDF)
- Quality Improvement (QI) Program
- Referral and Authorization Information
- Statement of Non-Discrimination
- Where To Go For Care
- Women's Health and Cancer Rights Act Annual Notice
Forms
- Authorization to Disclose Health Information Form (PDF)
- Revocation of Authorization Form (PDF)
- Member Grievance and Appeal Form (PDF)
- Member Reimbursement Medical Claim Form (PDF) - Used to submit a paid claim for Out of Country emergency services received from an out-of-network international provider.
- Pharmacy Program Forms
- Prescription Claim Reimbursement Form (PDF)
- Donor Transplant Travel Reimbursement Form (PDF)
- Recipient Transplant Travel Reimbursement Form (PDF)
- Member Transplant Travel Reimbursement Policy (PDF)
- Member Over The Counter Contraceptive Reimbursement Claim Form (PDF)