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.
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
