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- Member
- Medicare Member
Medical & vision claims
- Medical or Vision Claim Form
- Medicare Advantage Medical Claim Form Medicare Only
- International Claim Form
- Formulario de reclamación internacional
- International Claim Form in European A4 Paper Size
Prescription drug claims
- Prescription Drug Claim Form
- Medicare Advantage Prescription Drug Claim Form Medicare Only
- Dual Special Needs Plan (D-SNP) Prescription Drug Claim Form D-SNP Only
- Formulario de Coordinación de Beneficios/Reclamación de Reembolso de Medicamentos Recetados
Dental claims
Health spending & reimbursement
- FSA, HRA, and HSA Reimbursement Forms — Forms provided by Lifetime Benefit Solutions for Flexible Spending Account, Health Reimbursement Account, and Health Savings Account.
- Dual Special Needs Plan (D-SNP) OTC & Healthy Food Claim Form D-SNP Only
- SimplyBlue Gym Membership Incentive Reimbursement Form
Travel & lodging reimbursement
- Travel Reimbursement Form
- Medicare Advantage Transplant Travel & Lodging Claim Form Medicare Only
- Dual Special Needs Plan (D-SNP) Transplant Travel and Lodging Claim Form D-SNP Only
Coverage & billing
- Automated Premium Withdrawal Form Medicare Only
- Pediatric Dental Coverage Attestation Form
- Prior Coverage Verification Form
- Surprise Medical Bill Certification Form (PDF)
- Deluxe Item Upgrade Form
Membership & enrollment
- Adult Disabled Dependent Form
- Away From Home Care Guest Membership Application
- Continuing Coverage for Students on Medical Leave Form
- Dental Change Form — Individual & Family Plans
- Dependent Certification Form
- Medical Change Form — Individual & Family Plans
- Young Adult Option Certification Form
