Forms

Forms

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.

Arizona Claims Appeal Packet

Authorization to Disclose PHI

Claims Appeal Representative Authorization

Claim Upload Online

CMS 1500 Claim Form

COBRA Application

COBRA Application - Texas

Coordination of Benefits (COB)

COVID OTC Test Claim Form

Customer Relations Appeal

Disabled Dependent Coverage Application

EMI Health Vision Claim

EMI TeleMed Enrollment

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

Opticare Out-of-Network Claim

Outpatient Notification

Prescription Mail Order

Senior Dental Plans

UIEBT Loan Application

VSP Out-of-Network Claim

On this page

Member Forms

Employer Forms

Group Appeal Form

Group Application - Arizona

Group Application - EMI Health Telemed

Group Application - Georgia

Group Application - Texas

Group Application - Utah (Education)

Group Application - Utah (Non-Education)

Group/Broker Online Portal Request

On this page

Employer Forms

Provider Forms

CMS 1500 Claim Form

Dental Provider Manual

Medical Provider Manual

Outpatient Notification/Pre-authorization

On this page

Provider Forms

Broker Forms

Arizona Group Application

Broker Appeal Form

Education Group Application (UT)

EMI Health Telemed Group Application

Group/Broker Online Portal Request

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

On this page

Broker Forms