Important Documents & Forms

Privacy Authorization form

Your provider will use this form to get your permission to share your protected health information with a third party for personal use, insurance, continued medical care, or other reasons.  You do not have to sign this form as it is voluntary. If you do not sign the authorization form, we will not release protected health information to a third party. 

Automatic Deduction request form

Automatic Deduction request form (Checking/Savings)

Use this form to request an automatic monthly premium deduction from your checking or savings account. You may also use this form to update your bank account information when you are having premiums deducted from your specified account.

 

Provider Payment Guide & Invoice

If your claim has been approved, you can use the payment guides listed below based on the level of care you are receiving during your eligibility period.  These forms are used for reimbursement purposes and outline the documents necessary to help facilitate the processing of your reimbursement. Please do not submit invoices until services have incurred:

Direct Deposit form & Fraud language (Individual)

If your claim has been approved and you would like the reimbursement direct deposited to the insured’s bank account, please complete and return one of the following direct deposit forms. You can use this form to enroll or change your direct deposit information.  If you need clarification, you may contact your Care Coordinator with any questions:

Direct Deposit form & Fraud language (Group)

If your claim has been approved and you would like the reimbursement direct deposited to the insured’s bank account, please complete and return one of the following direct deposit forms. You can use this form to enroll or change your direct deposit information.  If you need clarification, you may contact your Care Coordinator with any questions:

 

Lapse Designee Form

Use this form if you would like to designate someone in addition to yourself to receive a copy of the final billing notice.