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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!
Member Handbook
Reference Materials
- Doctor's Office Visit Checklist (PDF) - Use this checklist to get prepared for your next doctor's appointment.
- Statement of Non-Discrimination
- 2020 Transparency Notice
- 2019 Transparency Notice
- Preventive Services Guide (PDF)
- Where to go for Care
- Women's Health and Cancer Rights Act Annual Notice
- Member Appeals
- Balance Billing
Forms
- Authorization to Disclose Health Information Form (PDF)
- Revocation of Authorization Form (PDF)
- Member Reimbursement Medical Claim Form (PDF)
- Continuity of Care Assistance Form - English (PDF)
- Continuity of Care Assistance Form - Spanish (PDF)
- Coordination of Care Form (PDF)
- Prescription Claim Reimbursement Form (PDF)
- Grievance and Appeals Form (PDF)
- Appointment of Representative Form (PDF)
- Donor Transplant Travel Reimbursement Form (PDF)
- Recipient Transplant Travel Reimbursement Form (PDF)
- Member Transplant Travel Reimbursement Policy (PDF)