Authorization for Appeals - Use this form to provide your approval for another party to submit an appeal on your benefit.
Member Appeal Form - Use this form to request an appeal of a decision.
Appeal Submission Form - Use this form to resolve billing issues that directly impact payment or a write-off amount.
Complaint and Appeal Rights - Learn about your appeal rights.
Claim Form - Need to file a claim? Start here
FSA/HRA Expense Manual Claim Form - Use this if you have an FSA (Flexible Spending Account) or HRA (Health Reimbursement Arrangement) to get reimbursed for eligible out-of-pocket medical expenses.
HSA Expense Manual Claim Form - Use this if you have an HSA (Health Savings Account) to get reimbursed for qualified out-of-pocket medical expenses.
Incident Questionnaire - You may be asked to complete this form after sustaining an injury or being involved in an accident.
Dependent Care Account Claim Form
Other Coverage Questionnaire - You may be asked to complete this form to provide information about other coverage you may have.
Authorization for Release of Psychotherapy Notes - Complete this form to allow access to notes made by medical professionals providing psychiatric or psychological services.
Benefit and Claim Information Authorization Release - Use when release of benefit, claim, or personal information is required.
Disclosure Accounting Request - Use this form to request a record of how we disclose information about you for reasons other than our normal business functions.
Non-Disclosure Request Form - Use this form to tell us your requests concerning sharing your health information.
Request for Amendment of Records - Change your official personal information we maintain using this form.
Request for Inspection of Records - Use this form to request certain records that we maintain containing your personal information.
For Metallic Plans
Declaration of Domestic Partnership
Individual Adult Dental Copay Plan - Application to add adult dental coverage to an Individual metallic plan
UMB HSA Account Application - An application to help set up an HSA bank account at UMB Bank
Tobacco Certification Form - For plans as of 1/1/14 enrollment dates
Application for the Addition of Family Members - Application to add family members to an existing policy. For grandfathered plans.
Standard Health Questionnaire - For plans effective with enrollment date on or after March 23, 2012
Non-Smoker Certification - This form is to be completed when subscriber and/or spouse/domestic partner has not used tobacco products 12 months preceding submittal of this form.
Grandfathered Plans Dental Copay Listing
Grandfathered Plans Dental Sales Brochure
Employers in Clark County
Affidavit of Domestic Partnership - Complete this form to verify a domestic partnership.
Case Management Referral Form - File this form to make a case management request.
Deductible Credit Form - This form is used to verify deductibles applied toward plan members.
Waiver of Coverage - This form is used to decline coverage by an employee.
Member Enrollment and Change Application - This form is used to enroll an employee as a member.
Member Enrollment and Change Application - Spanish Version - Spanish version of the form used to enroll an employee as a member.
Group Master Application 51+ - For Clark County only.
Disabled Dependent Request for Certification - This form is filed by the employee to enroll a disabled dependent.
Discount Card Reimbursement - This form is only to be used for Affordable Care Act (ACA) Health Care Reform mandated prescription reimbursement for members on the Drug Discount Program.
Prescription Drug Reimbursement - Apply for reimbursement of your prescription costs.
Express Scripts Mail-Order Form - Want your prescription drugs delivered directly to you at home? Use this form.
Health, Allergy & Medication Questionnaire - Complete this questionnaire for all new mail prescriptions to help protect yourself against potentially harmful drug interactions and side effects.
Secondary Coverage Claim Form - Are you covered by more than one health plan, with LifeWise as your secondary coverage? If so, you can request reimbursement for the balance of your prescription costs.
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