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Frequently used health care forms

Download and print the health plan form you need.

Authorization for the Release of Protected Health Information Form
Appointment of Representation Form
CMS Determination Form
CMS Medicare Complaint Form
Coverage Determination Form
Coverage Redetermination Form
Direct Member Reimbursement Form
Express Scripts Home Delivery Order Form
Non-plan Provider Claim Form
OptumRx New Prescription Mail In Order Form
Payment Option Form
Walgreens Mail Order Service Form

If you don’t see the form you’re looking for, contact us here, or call the toll-free Customer Service number on the back of your member ID card.