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Forms

Whether you need to submit a wellness reimbursement request or file an appeal, we can help. Not sure what form to use? Call Us: 855-442-9900 (TTY: 711)

Forms

Frequently Used Forms

picture_as_pdf  Wellness Reimbursement Form (English)

picture_as_pdf  Wellness Reimbursement Form One Page (English)

picture_as_pdf  Authorization to Release Health Information

 

Appeals and Grievances

picture_as_pdf  Appeal Form

picture_as_pdf  Formulario de apelación

picture_as_pdf  Grievance Form

picture_as_pdf  Formulario de agravio

picture_as_pdf  CMS Appointment of Representative

picture_as_pdf  Nombramiento de un Representante

 

Health Information Release

picture_as_pdf  Authorization to Release Health Information

picture_as_pdf  Autorización para divulgar información de salud

 

LiVeWell Advantage

link  Online Wellness Reimbursement Form

picture_as_pdf  Wellness Reimbursement

picture_as_pdf  Wellness Reimbursement One Page

picture_as_pdf  Imprimir el formulario de reembolso de bienestar

picture_as_pdf  Imprimir el un página formulario de reembolso de bienestar

 

Healthy Living (Utah and Idaho Only)

picture_as_pdf  Healthy Living Instructions

picture_as_pdf  Instrucciones para Healthy Living

 

Pharmacy

picture_as_pdf  Coverage Determination Form

picture_as_pdf  Prescription Reimbursement Form

picture_as_pdf  Formulario de Reembolso de Recetas

picture_as_pdf  Vaccine Reimbursement Form

picture_as_pdf  Part D Redetermination Request Form

link  Intermountain Home Delivery Online Enrollment Form

picture_as_pdf  Intermountain Home Delivery Enrollment Form

 

Premium Payment

picture_as_pdf  Authorization Agreement for Electronic Funds Transfer Form

 

Claims Reimbursement

picture_as_pdf  Medical Claim Reimbursement Request Form

picture_as_pdf  Eyewear Reimbursement Request Form

 

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

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

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

picture_as_pdf  Over-the-Counter (OTC) Product Guide

picture_as_pdf  Catalago de productos de venta libra (OTC)

picture_as_pdf  Productos de venta libra (OTC) formulario de pedido

 

Optional Dental and Vision Enrollment

picture_as_pdf  2019 Utah Optional Dental and Vision Enrollment/Disenrollment Form

picture_as_pdf  2019 Idaho Optional Dental and Vision Enrollment/Disenrollment Form

picture_as_pdf  2019 Nevada Optional Dental and Vision Enrollment/Disenrollment Form

 

Provider

picture_as_pdf  Waiver of Liability Form