Member Handbooks and Forms

• 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.

• Health Home Brochure - English (PDF) 
• Health Home Brochure - Spanish (PDF)
• Health Home Member Booklet (PDF)
• Health Home Opt-Out Form (PDF)
• Health Home Information Sharing Consent Form (PDF)
• Health Home Adolescent Information-Sharing Consent (PDF)

• 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