Member Forms
The forms below may not be applicable to all EMI Health plans. For specifics on your plan, please see your plan documents or contact customer service at 801-262-7475 or toll free at 800-662-5851.
Claims Appeal Representative Authorization
Coordination of Benefits (COB)
Disabled Dependent Coverage Application
Express Scripts COB/Direct Claim Form
Express Scripts COB/Formulario de Reclamo
Express Scripts Formulario de Pedido de Entrega a Domicilio
Individual Health Questionnaire
Member Appeal Form - Enrollment
Mini COBRA Application - Arizona
Mini COBRA Application - Georgia
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Broker Forms
Mini COBRA Application - Arizona
Mini COBRA Application - Georgia
Mini COBRA Application - Texas
Education Group Application (UT)
EMI Health Telemed Group Application
Group/Broker Online Portal Request
Group and Plan Information (Spanish)
Group Risk Evalution (Spanish)
Individual Health Questionnaire
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If you are a participating provider located in Utah, do not use this form. Contact your provider relations representative.