Individual Marketplace Forms

    Primary Care Physician Designation Form

    Prescription Reimbursement Claim Form

    HIPAA Release Form  - Print Version

    HIPAA Release Form  - Electronic Docusign Version

    Transition of Care Request Form

    Medical Claim Form

    Non-Formulary Exceptions Request Form

    Appointment of Representative Form

    Grievance Form
This fillable form is used by members to file a Grievance. This form is for traditional printing and mailing. For most efficient processing of your Grievance, we recommend filing it electronically through our member portal by clicking here.

    Appeal Request Form
This form is for traditional printing and mailing. For most efficient processing of your Appeal, we recommend filing it electronically through our member portal by clicking here.