Forms and other important documents
Covered services lists
Provider and pharmacy directory
Health Quality and Equity Strategic Plan
Medical claim form (Request for Payment of Medical Services)
Use this form to request repayment of a performed medical service.
Pharmacy claim form (Request for Payment of Pharmacy Services)
Use this form to request repayment of pharmacy services.
Personal representative forms
- Personal Representative Authorization Form
This form gives us permission to share your personal information to another person and/or gives permission to someone else to file an appeal for you. - Request for an Accounting of Disclosures of Personal Information form
Use this form to ask us for a list of people we have shared your information with for reasons other than treatment, payment, or health care operations. - Restriction form
This form requests limits on how we use or share your personal information.
