Forms and information

Forms

Call us at 844-427-8501 if you need help with these forms.

Appeal filing form Authorization for release of protected health information Continuity of care request form Late self-payment request/appeal form Life insurance beneficiary form Mail order pharmacy form PHI restriction request form Prescription reimbursement claim form Request to inspect or receive a copy of protected health information 1095-B tax form

Health Connect Newsletter

Information

Get to know your benefits. That will help you know what is available to you. To find out about your benefits call us at 844-427-8501.