Member Handbooks and Forms
To view more details on covered benefits, visit the Benefits and Services section. Select the Benefits Overview that is relevant to you for a summary and a more detailed, printable list.
- Appeal Form for Member Authorized Representative
- Primary Care Physician (PCP) Change Form - English | Spanish
- Authorization to Disclose Personal Health Information - English | Spanish
- Revocation of Authorization to Disclose Health Information - English | Spanish
- Member Grievance Form
- DME Referral Form
- Prescription Claim Reimbursement Form
Health Home Services Resources
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.