Member Forms

Arizona Claims Appeal Packet

Authorization to Disclose PHI

Claims Appeal Representative Authorization

Claim Upload Online

CMS 1500 Claim Form

COBRA Application

COVID OTC Test Claim Form

Customer Relations Appeal

Dental Claim

Disabled Dependent Coverage Application

EMI Health Vision Claim

EMI TeleMed Enrollment

EOB Opt-out

Express Scripts COB/Direct Claim Form

Express Scripts COB/Formulario de Reclamo

Express Scripts Formulario de Pedido de Entrega a Domicilio

Individual Health Questionnaire

Opticare Out-of-Network Claim

Outpatient Notification

Prescription Formulary 2021

Prescription Mail Order

Senior Dental Plans

UIEBT Loan Application

VSP Out-of-Network Claim

Employer Forms

Group Application - Arizona

Group Application - EMI Health Telemed

Group Application - Georgia

Group Application - Texas

Group Application - Utah (Education)

Group Application - Utah (Non-Education)

Provider Forms

Address Change

EFT Enrollment

CMS 1500 Claim Form

Dental Provider Manual

Medical Provider Manual

Outpatient Notification/Pre-authorization

Broker Forms

Arizona Group Application

Education Group Application (UT)

EMI Health Telemed Group Application

Group and Plan Information

Group and Plan Information (Spanish)

Group Risk Evalution

Group Risk Evalution (Spanish)

Individual Health Questionnaire

Quoting Medical Rates Checklist

Texas Group Application

Utah Group Application