1-800-868-5200 (TRS 711)Mon., Tue., Thu., Fri.: 8 a.m. to 6 p.m. Wed: 10 a.m. to 6 p.m.
for:
Tax forms Learn more about the 1095 and 1099-HC forms you need for your tax filings.
It Fits! reimbursement form Complete this form to receive reimbursement for health club memberships, school sports league fees, and more.
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.
Pharmacy claim form (Request for Payment of Pharmacy Services) - for claims dated before 1/1/2022 Use this form to request repayment of pharmacy services.
Personal Representative Authorization form This form is for Fallon Health members to give permission to Fallon to disclose your personal information to a designated person and/or to give permission to someone else to file an appeal on your behalf.
Personal Representative Authorization Form This form is for Fallon MassHealth members to give permission to Fallon to disclose your personal information to a designated person and/or to give permission to someone else to file an appeal on your behalf.
Amendment Request for Personal Information form This form is used to ask us to make changes to your record if you think it is inaccurate or incomplete. You do not need to use this form for corrections to your address, date of birth or name.
Authorization for Release of Personal Information form This form authorizes Fallon Health to give your personal information to another individual or entity (such as your employer, if they are working on your behalf to resolve a claim issue).
Request for an Accounting of Disclosures of Personal Information form This form is used to request a listing of who Fallon Health has shared your information with for reasons other than treatment, payment or health care operations. Please note there are limitations to the number of prior years you may request.
Restriction form This form is used to put limitations on how we use or share your personal information.
For Fallon Medicare Plus and NaviCare members, please visit the forms page for Fallon Medicare Plus and the forms page for NaviCare.