Member Handbooks and Forms
- Appeal Form for Member Authorized Representative (PDF)
- Apple Health Core Connections Interim Voucher (PDF)
- Primary Care Physician (PCP) Change Form - English (PDF)
- Primary Care Physician (PCP) Change Form - Spanish (PDF)
- Authorization to Disclose Personal Health Information - English (PDF)
- Authorization to Disclose Personal Health Information - Spanish (PDF)
- Revocation of Authorization to Disclose Health Information - English (PDF)
- Revocation of Authorization to Disclose Health Information - Spanish (PDF)
- Member Grievance Form (PDF)
- DME Referral Form
- Prescription Claim Reimbursement Form (PDF)
Health Home is a set of services to assist members with chronic conditions, like diabetes, asthma, heart disease and others. Our care coordinators help you create a plan to improve and support your care. For more information, check out the links below.