Forms

Not all forms apply to your benefits plan. Sign in to your account to find specific forms relating to your coverage. If you have any questions about which forms or documents you may need, please call the toll–free number on your health plan ID card.

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pdf ABA Therapy Request form (UMF0035)
pdf At Home COVID-19 Test Kit Reimbursement Form
pdf Authorization for Release of Health Information
pdf Authorization For Release of Protected Health Care Information
pdf Baptist Health Quality Network Referral Authorization
pdf Contraceptive Management Mobile Application Reimbursement Form (UMF0031)
pdf Dental Claim Form
pdf Dependent Care Flex Claim Form
pdf Eligible/Ineligible Flex Expense Lists
pdf Employee Questionnaire: Request for other medical/dental insurance information
pdf Flexible Spending Claim Form - Dependent Daycare FSA
pdf Flexible Spending Claim Form - Health Care FSA
pdf Health Care Flex Claim Form
pdf Medical claim form
pdf Medical Claim form (EZ Claim) (UMF0022)
pdf NMHS Referral Form
pdf Other Insurance Form – Medical only (UMF0021, formerly FS0733)
pdf Patient Rights Summary
pdf Post-Service Appeals Designation of Authorized Representative (UMF0018)
pdf Post-Service Appeal Member Request Form (UMF0010)
pdf Predetermination Request Form
pdf Pre-service appeals designation of authorized representative (UMF0011)
pdf Prior Authorization Fax Sheet
pdf Privacy Complaint Form
pdf Provider Remittance Advice (RA) form (UMF0025)
pdf Request for Amendment of Protected Health Information
pdf Request for An Accounting of Disclosures of Protected Health Information
pdf Request for Confidential Communications of Protected Health Information
pdf Request for confidential information form (UMF0024)
pdf Revocation of Request for Confidential Communications of Protected Health Information
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