Forms

Frequently Used Forms

  Wellness Reimbursement Form (English)

  Wellness Reimbursement Form One Page (English)

  Authorization to Release Health Information

 

Appeals and Grievances

  Appeal Form

  Formulario de apelación

  Grievance Form

  Formulario de agravio

  CMS Appointment of Representative

  Nombramiento de un Representante

 

Health Information Release

  Authorization to Release Health Information

  Autorización para divulgar información de salud

 

LiVeWell Advantage

  Online Wellness Reimbursement Form

  Wellness Reimbursement

  Wellness Reimbursement One Page

  Imprimir el formulario de reembolso de bienestar

  Imprimir el un página formulario de reembolso de bienestar

 

Healthy Living (Utah and Idaho Only)

  Healthy Living Instructions

  Instrucciones para Healthy Living

 

Pharmacy

  Coverage Determination Form

  Prescription Reimbursement Form

  Formulario de Reembolso de Recetas

  Vaccine Reimbursement Form

  Part D Redetermination Request Form

  Intermountain Home Delivery Online Enrollment Form

  Intermountain Home Delivery Enrollment Form

 

Premium Payment

  Authorization Agreement for Electronic Funds Transfer Form

 

Claims Reimbursement

  Medical Claim Reimbursement Request Form

  Eyewear Reimbursement Request Form

 

Over-the-Counter (OTC) Benefit (Nevada Only)

  Online Over-the-Counter (OTC) Product Order Form

  Over-the-Counter (OTC) Product Order Form

  Over-the-Counter (OTC) Product Guide

  Catalago de productos de venta libra (OTC)

  Productos de venta libra (OTC) formulario de pedido

 

Optional Dental and Vision Enrollment

  2019 Utah Optional Dental and Vision Enrollment/Disenrollment Form

  2019 Idaho Optional Dental and Vision Enrollment/Disenrollment Form

  2019 Nevada Optional Dental and Vision Enrollment/Disenrollment Form

 

Provider

  Waiver of Liability Form