Find the form you need for:

Network Advantage

Generally, claims will be submitted by your network provider. However, if you use a non-network provider, you will need to submit the claim.

Mail completed claims forms to:
 

Claims Processing
P.O. Box 30755
Salt Lake City, UT 84130-0755
 

Note regarding medical claims:

If you have questions or concerns regarding a medical claim, please refer to the phone number on your insurance card.

Managing your health

Managing Your Healthcare Information - The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule gives you rights over your protected health information (PHI), including the right to get it, change it, share it and monitor it. The forms on the following page will help you manage your healthcare information.

Appointment of Representative - A Commercial member (or “patient”) may use this form to designate an authorized representative to act on his or her behalf regarding a grievance, or an appeal of a denial of service or payment.