Members

Forms

icon PDF Member Grievance and Appeals Request Form (English | Spanish)
icon PDF Medical Release Form (English | Spanish)
icon PDF Authorization for the Use and Disclosure of PHI (English | Spanish)
icon PDF Member access to PHI (English | Spanish)
icon PDF Freedom of Choice (English | Spanish | French Creole)

icon PDF Direct Member Reimbursement (DMR) (English | Spanish)

 

You may have to pay for services that are not covered. You may also have to pay for services from providers not part of our network. If the services were an emergency, you don’t have to pay. If you need help, call Member Services.