Forms

Medical Claim Form for Group and Individual & Family Plans

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

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)

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.