Forms

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 Grievance Form
•	Member Reimbursement Form — Medical Services
•	Member Reimbursement Form — Prescription Drugs
•	Question About A Bill
•	Request for Continuity of Care Benefits
•	Student Verification

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