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.
Integrated Managed Care Member Handbook
*(updated with new Ombuds phone numbers)
- Apple Health Integrated Managed Care - English (PDF)*
- Apple Health Integrated Managed Care - Spanish (PDF)*
- Apple Health Integrated Managed Care - Chinese (PDF)*
- Apple Health Integrated Managed Care - Russian (PDF)*
- Apple Health Integrated Managed Care - Vietnamese (PDF)*
Behavioral Health Services Only
*(updated with new Ombuds phone numbers)
- Appeal Form for Member Authorized Representative (PDF)
- Appeal Request form (PDF)
- Authorization to Disclose Personal Health Information - English (PDF)
- Authorization to Disclose Personal Health Information - Spanish (PDF)
- DME Referral Form
- Member Grievance Form (PDF)
- Member Reimbursement Medical Claim Form - English (PDF)
- Member Reimbursement Medical Claim Form - Spanish (PDF)
- Notification of Pregnancy (NOP) form (members) - English (PDF) | Spanish NOP (PDF)
- Prescription Claim Reimbursement Form (PDF)
- Primary Care Physician (PCP) Change Form - English (PDF)
- Primary Care Physician (PCP) Change Form - Spanish (PDF)
- Record Request Form - English (PDF)
- Record Request Form - Chinese (PDF)
- Record Request Form - Korean (PDF)
- Record Request Form - Russian (PDF)
- Record Request Form - Spanish (PDF)
- Record Request Form - Vietnamese (PDF)
- Revocation of Authorization to Disclose Health Information - English (PDF)
- Revocation of Authorization to Disclose Health Information - Spanish (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.
- Adult Immunization Record (PDF)
- Advance Directives One-sheet - English and Spanish (PDF)
- Tobacco Cessation Program Description
- Medically Intensive Children's Program (MICP) flyer - English (PDF)
- Medically Intensive Children's Program (MICP) flyer - Spanish (PDF)
- Preventive Health and Clinical Practice Guidelines