Form library

Generally, in-network claims will be submitted by your network provider. However, if you use an out-of-network provider, you’ll need to submit the claim yourself online or through mail.

You’ll be asked to sign in, if you haven’t already.

For corrected claims, adding supporting documents and other instances, you’ll need to submit a claim by mail.

Mail your form to: Claims processing, PO Box 30755, Salt Lake City, UT 84130-0755

Use this form to allow your behavioral health provider to contact your medical doctor. This is important because you may receive medication from both providers, and some medicines can interact negatively. Your doctors need to know all the medicines that you’re taking and any medical issues you have to ensure you receive the best and safest treatment.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule gives you the right to access, amend, share and monitor your health info. The forms on the next page will help you manage that info.

This form gives permission to share your personal info with people you choose, like family, doctors and insurance companies. You’ll need to include all necessary documents and electronically sign the form. If you have an Illinois address, you can’t use this electronic form due to state law.

Complete this brief pre-visit questionnaire about your emotions and feelings. Take and review it with your clinician to help get services to best meet your needs.

Use this form if you would like to file a complaint or appeal. You may also file a complaint or appeal by calling the number on the back of your health plan card.

A commercial member (or “patient”) may use this form to designate an authorized representative to act on their behalf regarding a grievance, payment appeal or denial of service appeal.