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.

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Forms for Members

 Authorizations

PDF icon Online Access / PHI Disclosure Form

PDF icon Member Authorization to Obtain PHI

PDF icon Member Authorization to Release PHI

Flexible Spending Account (FSA) & Health Reimbursement Arrangement (HRA)*

PDF icon FSA Claim Form

PDF icon HRA Claim Form

PDF icon FSA-OTC Claim Form

PDF icon FSA Transit/Parking Claim Form

PDF icon FSA/HRA Direct Deposit Form

Member Appeal

PDF icon Member Appeal Form

Member Reimbursements*

PDF icon Standard Medical Claim Form

PDF icon Standard Dental Claim Form

PDF icon Member Reimbursement Form  green starsubmit your request in My Plan

PDF icon Short Term Disability Form

PDF icon Fitness Reimbursement Form  green starsubmit your request in My Plan

PDF icon Weight Loss Reimbursement Form  green starsubmit your request in My Plan

 

*Claim and reimbursement forms may not be applicable to all plans. Be sure to check your benefit details in your summary plan description prior to submitting a claim or reimbursement form.

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