Forms & Resources

At Health Plans, we take our commitment to your health very seriously. That’s why we want to be a key source of tools and information to help you be the healthiest you you can be.

Would you like to:

Print a form?

Order an ID Card?

Forms for Members

 Authorizations & Verifications

 Online Access / PHI Disclosure Form

 Member Authorization to Obtain PHI

 Member Authorization to Release PHI - Care Management Services

 Member Authorization to Release PHI - Claims

 Out-of-Area Dependent Coverage Verification Form - Select Plan

 Out-of-Area Dependent Coverage Verification Form - Tiered HMO Plan

 Transition of Care Request Form

Member Appeal

 Member Appeal Form 

Request for Network Exception 

 Network Exception Request Form

Member Reimbursements

 Standard Medical Claim Form

 Member Reimbursement Form  submit your request in My Plan

 Fitness Reimbursement Form  submit your request in My Plan

 Travel Reimbursement Form  submit your request in My Plan

Some forms on this page are in PDF format and require Adobe Reader to open.