Member Care

• Member Services
• Member Advocates
• Behavioral Health Advocates
• Forms
• FAQs
• Secure Messaging
• About SelectHealth

Member Forms

• Medical Change Form
• Dental Change Form
• HIPUtah Change Form
• Individual Plan Application (eff. 9/16/10 and prior)
• Individual Plan Application (eff. 10/1/10 forward) 
• Individual Reapplication
• Kids Plan Application
• Transition Plan Application
• Appeal Form
• Appeal Form - Spanish

Small Employer Forms

• SE Change Form
• Formulario de cambio
• SE NationCare Change Form
• SE Employee Application
• Solicitud del empleado - Empleadores
• SE NationCare Application
• Waiver Form
• Formulario de renuncia a la cobertura
• NationCare - Waiver Form

Large Employer

• Large Employer Enrollment
• Large Employer Enrollment - Idaho 
• Formulario de inscripción para el empleador de gran capital en Utah
• NationCare LE Enrollment Form
• Change Form
• Formulario de cambio
• Change Form - NationCare
• Secondary Medical Coverage

Disclosure Authorization Form

• Authorization to Disclose Information
• Autorización para revelar la información médica
• Authorization to Release Health Information for Care Management

Pharmacy Forms

• Prescription Drug List
• RXCore Drug List
• Medco By Mail Order Form
• Medco Questionnaire
• Prescription Drug Reimbursement Form - English
• Formulario para el reembolso de medicamentos recetados