Member Forms
Claims Appeal Representative Authorization
Disabled Dependent Coverage Application
Express Scripts COB/Direct Claim Form
Individual Health Questionnaire
Opticare Out-of-Network Claim - AZ
Opticare Out-of-Network Claim - AZ (Spanish)
Opticare Out-of-Network Claim - UT
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If you are a participating provider located in Utah, do not use this form. Contact your provider relations representative.