Forms & Resources
At Health Plans, we take our commitment to your health very seriously. That’s why
we want to be a key source of tools and information to help you be the healthiest you
you can be.
Would you like to:
Forms for Members
Authorizations & Verifications
Online Access / PHI Disclosure Form
Member Authorization to Obtain PHI
Member Authorization to Release PHI - Care Management Services
Member Authorization to Release PHI - Claims
Out-of-Area Dependent Coverage Verification Form - Select Plan
Out-of-Area Dependent Coverage Verification Form - Tiered HMO Plan
Transition of Care Request Form
Member Appeal
Member Reimbursements
Member Reimbursement Form 
submit your request in My Plan
Fitness Reimbursement Form submit your request in My Plan
Travel Reimbursement Form submit your request in My Plan
Some forms on this page are in PDF format and require Adobe Reader to open.
