Forms

Self Funded Administrative Services

Administrative Services

Accident Questionnaire
Accident Questionnaire-Spanish
Authorization to Disclose PHI to a Third Party
Authorized Representative Form
Authorized Representative Form - Spanish
Benefits Enrollment/Change Form
Benefits Enrollment/Change Form-Spanish
Continuation of Care Form
Coordination of Benefits Form
Coordination of Benefits Form-Spanish
Dental Claim Form
Employee Termination Form
Mail Order Prescription Form (Optum Rx)
Mail Order Prescription Form (Optum Rx)-Spanish
Medical Benefits Short-Term Disability Claim Form
Medical Benefits Short-Term Disability Claim Form-Spanish
Medical Claim Form
Medical Claim Form-Spanish
Prescription Reimbursement Request Form
Short-Term Disability Claim Form
Short-Term Disability Claim Form-Spanish

TotalCare+ Flexible Solutions

Total Care+ logo

Indemnity Plan	MEC Plan	MVP
Authorized Representative Form - English Authorized Representative Form – Spanish Dental Claim Form - English Dental Claim Form – Spanish Medical Claim Form - English Medical Claim Form-Spanish Missed Premium Direct Payment Form - English Missed Premium Direct Payment Form-Spanish Prescription Drug Reimbursement Claim Form - English Prescription Drug Reimbursement Claim Form-Spanish Short-Term Disability / Proof of Loss Claim Form - English Short-Term Disability /Proof of Loss Claim Form – Spanish Term Life / Accidental Death and Dismemberment - English Vision Claim Form - English EyeMed Out of Network Vision Services Claim Form - English EyeMed Out of Network Vision Services Claim Form-Spanish	MEC Medical Claim Form - English MEC Medical Claim Form-Spanish MEC Missed Contribution Direct Payment Form Weekly - English MEC Prescription Drug Reimbursement Claim Form - English	MVP Coordination of Benefits Form - English

TotalCare+ Staffing Solutions

TotalCare+ Staffing Solutions Lobo

Indemnity Plan	MEC Plan	MVP
Authorized Representative Form - English Authorized Representative Form – Spanish Dental Claim Form - English Dental Claim Form – Spanish Medical Claim Form - English Medical Claim Form-Spanish Missed Premium Direct Payment Form - English Missed Premium Direct Payment Form-Spanish Prescription Drug Reimbursement Claim Form - English Prescription Drug Reimbursement Claim Form-Spanish Short-Term Disability / Proof of Loss Claim Form - English Short-Term Disability /Proof of Loss Claim Form – Spanish Term Life / Accidental Death and Dismemberment - English Vision Claim Form - English EyeMed Out of Network Vision Services Claim Form - English EyeMed Out of Network Vision Services Claim Form-Spanish	MEC Missed Contribution Direct Payment Form Weekly - English MEC Medical Claim Form - English MEC Medical Claim Form-Spanish MEC Missed Contribution Direct Payment Form Weekly - English MEC Prescription Drug Reimbursement Claim Form - English	MVP Coordination of Benefits Form - English

CareBasic Hospitality

CareBasic Hospitality Log

Indemnity Plan

MEC Plans

Accidental Death & Dismemberment Claim Form - English
Accidental Death Dismemberment Claim Form-Spanish
Accidental Dismemberment -Physician Statement - English
Accidental Dismemberment -Physician Statement-Spanish
Accidental Loss of Life, Limb or Sight Claim Form - English
Accidental Loss of Life, Limb or Sight Claim Form-Spanish
Accidental Loss of Limb or Sight - Physician Statement - English
Accidental Loss of Limb or Sight - Physician Statement- Spanish
Accidental Indemnity and Critical Illness Claim Form - English
Authorized Representative Form - English
Authorized Representative Form-Spanish
Dental Claim Form - English
Dental Claim Form-Spanish
EyeMed Out of Network Vision Services Claim Form - English
EyeMed Out of Network Vision Services Claim Form-Spanish
Medical Claim Form - English
Medical Claim Form-Spanish
Missed Premium Direct Payment Form - English
Missed Premium Direct Payment Form-Spanish
Prescription Drug Reimbursement Claim Form - English (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)
Prescription Drug Reimbursement Claim Form-Spanish (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)
Prescription Drug Reimbursement Request Form (Optum Rx) - English (Use this form if Rx group BXPAI is on your ID card. If you medical plan entitles you to pay a co-pay at the point of purchase and your prescription was not filed directly to OptumRx by the pharmacy, use this form to submit payment. If your medical plan entitles you to a discount at the point of purchase, and you file your receipts to PAI for reimbursement, please use the form above.)
Short-Term Disability / Proof of Loss Claim Form - English
Short-Term Disability / Proof of Loss Form-Spanish
Term Life Claim Form - English
Term Life Life Claim Form-Spanish
Termination / Loss of Coverage Form - English
Termination / Loss of Coverage Form-Spanish

MEC Medical Claim Form - English
MEC Medical Claim Form-Spanish
MEC Missed Contribution Direct Payment Form-for MEC Weekly Plan - English
MEC Prescription Drug Reimbursement Claim Form - English

CareBasic Staffing

Indemnity Plan

ESC5500

MVP

Accidental Death & Dismemberment Claim Form - English
Accidental Death Dismemberment Claim Form-Spanish
Accidental Dismemberment -Physician Statement - English
Accidental Dismemberment -Physician Statement-Spanish
Accidental Loss of Life, Limb or Sight Claim Form - English
Accidental Loss of Life, Limb or Sight Claim Form-Spanish
Accidental Loss of Limb or Sight - Physician Statement - English
Accidental Loss of Limb or Sight - Physician Statement- Spanish
Accidental Indemnity and Critical Illness Claim Form - English
Authorized Representative Form - English
Authorized Representative Form-Spanish
Dental Claim Form - English
Dental Claim Form-Spanish
EyeMed Out of Network Vision Services Claim Form - English
EyeMed Out of Network Vision Services Claim Form-Spanish
Medical Claim Form - English
Medical Claim Form-Spanish
Missed Premium Direct Payment Form - English
Missed Premium Direct Payment Form-Spanish
Prescription Drug Reimbursement Claim Form - English (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)
Prescription Drug Reimbursement Claim Form-Spanish (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)
Prescription Drug Reimbursement Request Form (Optum Rx) - English (Use this form if Rx group BXPAI is on your ID card. If you medical plan entitles you to pay a co-pay at the point of purchase and your prescription was not filed directly to OptumRx by the pharmacy, use this form to submit payment. If your medical plan entitles you to a discount at the point of purchase, and you file your receipts to PAI for reimbursement, please use the form above.)
Short-Term Disability / Proof of Loss Claim Form - English
Short-Term Disability / Proof of Loss Form-Spanish
Term Life Claim Form - English
Term Life Life Claim Form-Spanish
Termination / Loss of Coverage Form - English
Termination / Loss of Coverage Form-Spanish

ESC5500 Coordination of Benefits - English

MEC Medical Claim Form - English
MEC Medical Claim Form-Spanish
MEC Missed Contribution Direct Payment Form-for MEC Weekly Plans - English
MEC Prescription Drug Reimbursement Claim Form - English

MEC Plans

MEC Medical Claim Form - English
MEC Medical Claim Form-Spanish
MEC Missed Premium Direct Payment Form - English
MEC Missed Premium Direct Payment Form-Spanish
MEC Wellness and Preventive Reimbursement Claim Form - English

CareBasic Medical Staffing

CareBasic Medical Staffing Logo

Indemnity Plan

MEC Plans

Accidental Death & Dismemberment Claim Form - English
Accidental Death Dismemberment Claim Form-Spanish
Accidental Dismemberment -Physician Statement - English
Accidental Dismemberment -Physician Statement-Spanish
Accidental Loss of Life, Limb or Sight Claim Form - English
Accidental Loss of Life, Limb or Sight Claim Form-Spanish
Accidental Loss of Limb or Sight - Physician Statement - English
Accidental Loss of Limb or Sight - Physician Statement- Spanish
Accidental Indemnity and Critical Illness Claim Form - English
Authorized Representative Form - English
Authorized Representative Form-Spanish
Dental Claim Form - English
Dental Claim Form-Spanish
EyeMed Out of Network Vision Services Claim Form - English
EyeMed Out of Network Vision Services Claim Form-Spanish
Medical Claim Form - English
Medical Claim Form-Spanish
Missed Premium Direct Payment Form - English
Missed Premium Direct Payment Form-Spanish
Prescription Drug Reimbursement Claim Form - English (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)
Prescription Drug Reimbursement Claim Form-Spanish (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)
Prescription Drug Reimbursement Request Form (Optum Rx) - English (Use this form if Rx group BXPAI is on your ID card. If you medical plan entitles you to pay a co-pay at the point of purchase and your prescription was not filed directly to OptumRx by the pharmacy, use this form to submit payment. If your medical plan entitles you to a discount at the point of purchase, and you file your receipts to PAI for reimbursement, please use the form above.)
Short-Term Disability / Proof of Loss Claim Form - English
Short-Term Disability / Proof of Loss Form-Spanish
Term Life Claim Form - English
Term Life Life Claim Form-Spanish
Termination / Loss of Coverage Form - English
Termination / Loss of Coverage Form-Spanish

MEC Medical Claim Form - English
MEC Medical Claim Form-Spanish
MEC Missed Contribution Direct Payment Form-for MEC Weekly Plans - English
MEC Prescription Drug Reimbursement Claim Form - English

HIPAA

Access Request Form
Amendment Request Form
Authorization for Marketing (Health Plan)
Authorization to Disclose PHI to a Third Party
Complaint Form
Confidential Communication Request
Designation of Authorized Representative to Appeal
Disclosure Accounting Accounting Request
Notice of Privacy Practices-PAI
Notice of Privacy Practices-PAI (Spanish)
Restriction Request

HospitalityCARE

Indemnity Claim Forms

MEC Plans

Accidental Death & Dismemberment Claim Form - English
Accidental Death & Dismemberment Claim Form-Spanish
Accidental Dismemberment Claim Form (Attending Physician's Statement) - English
Accidental Dismemberment Claim Form (Attending Physician's Statement)-Spanish
Accidental Loss of Life, Limb or Sight Claim Form - English
Accidental Loss of Life, Limb or Sight Claim Form-Spanish
Accidental Loss of Limb or Sight Claim Form (Attending Physician's Statement) - English
Accidental Loss of Limb or Sight Claim Form (Attending Physician's Statement)-Spanish
Authorized Representative Form - English
Authorized Representative Form-Spanish
Dental Claim Form - English
Dental Claim Form-Spanish
EyeMed Out of Network Vision Services Claim Form - English
EyeMed Out of Network Vision Services Claim Form-Spanish
Medical Claim Form - English
Medical Claim Form-Spanish
Missed Premium Direct Payment Form - English
Missed Premium Direct Payment Form-Spanish
Prescription Drug Reimbursement Claim Form - English (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)
Prescription Drug Reimbursement Claim Form-Spanish (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)
Prescription Drug Reimbursement Request Form (OptumRx) - English (Use this form if Rx group BXPAI is on your ID card. If you medical plan entitles you to pay a co-pay at the point of purchase and your prescription was not filed directly to OptumRx by the pharmacy, use this form to submit payment. If your medical plan entitles you to a discount at the point of purchase, and you file your receipts to PAI for reimbursement, please use the form above.)
Short-Term Disability / Proof of Loss Claim Form - English
Short-Term Disability / Proof of Loss Claim Form-Spanish
Term Life Claim Form - English
Term Life Claim Form-Spanish
Termination / Loss of Coverage Form - English
Termination / Loss of Coverage Form-Spanish

MEC Medical Claim Form - English
MEC Medical Claim Form-Spanish
MEC Missed Premium Direct Payment Form - English
MEC Prescription Drug Reimbursement Claim Form - English

Benefits 4 Today

Claim Forms

Dental Claim Form - English
Dental Claim Form-Spanish
EyeMed Out-of-Network Claim Form - English
Medical Claim Form - English
Medical Claim Form-Spanish
Missed Premium Direct Payment Form - English
Missed Premium Direct Payment Form-Spanish
Prescription Drug Reimbursement Claim Form - English (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)
Prescription Drug Reimbursement Claim Form-Spanish (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)
Prescription Drug Reimbursement Request Form (OptumRx) - English (Use this form if Rx group BXPAI is on your ID card. If you medical plan entitles you to pay a co-pay at the point of purchase and your prescription was not filed directly to OptumRx by the pharmacy, use this form to submit payment. If your medical plan entitles you to a discount at the point of purchase, and you file your receipts to PAI for reimbursement, please use the form above.)
Short-Term Disability / Proof of Loss Claim Form - English
Short-Term Disability / Proof of Loss Claim Form-Spanish
Term Life / Accidental Death Claim Form - English
Term Life / Accidental Death Claim Form-Spanish

EssentialCARE

Indemnity Plan

MEC Plans

Accidental Death & Dismemberment Claim Form - English
Accidental Death & Dismemberment Claim Form-Spanish
Accidental Dismemberment Claim Form (Attending Physician's Statement - English)
Accidental Dismemberment Claim Form (Attending Physician's Statement)-Spanish
Accidental Loss of Life, Limb or Sight Claim Form - English
Accidental Loss of Limb or Sight Claim Form-Spanish
Accidental Loss of Limb or Sight Claim Form (Attending Physician's Statement) - English
Accidental Loss of Limb or Sight Claim Form (Attending Physician's Statement)-Spanish
Dental Claim Form - English
Dental Claim Form-Spanish
Eye Exam Claim Form - English
Medical Claim Form - English
Medical Claim Form-Spanish
Missed Premium Direct Payment Form - English
Missed Premium Direct Payment Form-Spanish
Prescription Drug Reimbursement Claim Form - English (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)
Prescription Drug Reimbursement Claim Form - Spanish (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)
Prescription Drug Reimbursement Request Form (OptumRx) - English (Use this form if Rx group BXPAI is on your ID card. If you medical plan entitles you to pay a co-pay at the point of purchase and your prescription was not filed directly to OptumRx by the pharmacy, use this form to submit payment. If your medical plan entitles you to a discount at the point of purchase, and you file your receipts to PAI for reimbursement, please use the form above.)
Short-Term Disability / Proof of Loss Claim Form - English
Short-Term Disability / Proof of Loss Claim Form-Spanish
Term Life Claim Form - English
Term Life Claim Form-Spanish
Term Life / Accidental Death Claim Form - English
Term Life-Accidental Death Claim Form-Spanish
Termination / Involuntary Loss of Coverage Form - English
Termination / Involuntary Loss of Coverage Form-Spanish
Vision Out of Network Claim Form - English
Vision Out of Network Claim Form-Spanish