Forms

Medical Claim Form for Group and Individual & Family Plans

• Medical Claim Form – English (PDF)
• Medical Claim Form – En Español (Spanish) (PDF)

Complete the claim form for each member submitting bills for reimbursement of covered services. To avoid any delay, be sure to answer each question completely. PLEASE ATTACH FULLY ITEMIZED BILLS AND PROOF OF PAYMENT.

Proof of payment includes:

• Copy of cancelled check (front and back) or online bank statement
• Copy of credit card statement or bank statement

NOTE:

• Proof of payment on a Dr.'s prescription form is not acceptable.
• Invoices are not acceptable forms of proof of payment.

Non-Medicare – Behavioral Health (MHN) – Claim Form

Behavioral Health (MHN) – Claim Form – English (PDF)

Group Member Grievance Form

• Commercial GRIEVANCE FORM – English (PDF)
• Commercial GRIEVANCE FORM – En Español (Spanish) (PDF)
• Commercial GRIEVANCE FORM – Chinese (PDF)

Please explain in detail the circumstances that led to your dissatisfaction with Health Net. Please include the original copy of any claims or bills received which are related to your issue.

Transition of Care

• Continuity of Care Request Form – English (PDF)
• Continuity of Care Request Form – En Español (Spanish) (PDF)

Authorization For Disclosure of PHI

• Authorization For Disclosure of PHI – English (PDF)
• Authorization For Disclosure of PHI – En Español (Spanish) (PDF)
• Authorization For Disclosure of PHI – Chinese Mandarin – 中文 (PDF)
• Authorization For Disclosure of PHI – Korean – 한국어 (PDF)

Glossary of Health Coverage and Medical Terms

• Glossary of Health Coverage and Medical Terms – English (PDF)
• Glossary of Health Coverage and Medical Terms – En Español (Spanish) (PDF)
• Glossary of Health Coverage and Medical Terms – Chinese Mandarin – 中文 (PDF)
• Glossary of Health Coverage and Medical Terms – Navajo – Diné bizaad (PDF)
• Glossary of Health Coverage and Medical Terms – Korean – 한국어 (PDF)

Health insurance companies and group health plans are required to make available a uniform glossary of health coverage and medical terms commonly used in plan documents. The Uniform Glossary is meant to help the consumer understand some of the most common language used in health insurance documents. Please log in to request a hardcopy of the document by mail.