Forms

 

Claims

PDF icon Standard Medical Claim Form

PDF icon Standard Dental Claim Form

Microsoft Word icon Supplemental Claim Form

PDF icon Short Term Disability Form

Microsoft Word icon Fitness Reimbursement Form

Microsoft Word icon Weight Loss Reimbursement Form


Appeals

Microsoft Word icon Member Appeal Form

PDF icon Health Plans General Provider Appeal Form (non HPHC)

PDF icon Harvard Pilgrim Provider Appeal Form and Quick Reference Guide


COBRA Enrollment

PDF icon COBRA Qualifying Event Termination Form


Authorizations

PDF icon Prior Authorization Request Form

PDF icon Employer Portal Access Form

Microsoft Word icon Online Access / PHI Disclosure Form

PDF icon Member Authorization to Obtain PHI

PDF icon Member Authorization to Release PHI

 

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