Forms and Resources

These commonly requested forms are provided to assist you in getting the information you need.

•	Authorization for Use or Disclosure of Personal Health Information — English
•	Authorization for Use or Disclosure of Personal Health Information — Spanish
•	Deductible Credit Request
•	Designation of Personal Representative
•	Mail Order Prescription Drug Order Form
•	Medicare/Other Insurance Coverage Questionnaire
•	Member Appeal/Grievance Form
•	Member Reimbursement Form — Medical Services
•	Member Reimbursement Form — Prescription Drugs
•	Question About A Bill
•	Request for Continuity of Care Benefits

As always, if you can’t find what you’re looking for, please don’t hesitate to pick up the phone and call Customer Care at (619) 228-2300, toll-free at 1-800-359-2002 or send an e-mail via our Contact Us Form. Customer Care representatives are available Monday through Friday, 8 am to 6 pm.

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Forms and Resources