Forms and information


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


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.