Forms and Applications

Accidental Dismemberment or Loss of Sight Claim Form (Rev. 04/07/10)
Application for HealthChoice Employer PDP Medicare Supplement With Part D (Rev. 09/08/09)
Application for Retiree/Vested/Non-Vest/Defer Insurance (Rev. 07/09/10)
Beneficiary Designation Form (Rev. 08/06/09)
Change of Address Form (Rev. 08/03/10)
Pharmacy Direct Claims form for Pre-Medicare and Medicare Supplement without Part D Members (Rev. 04/06)
HIPAA Authorization to Disclose Health Information (Rev. 01/14/08)
HIPAA Complaint Form – Privacy (Rev. 08/03/05)
HIPAA Complaint Form – Other than Privacy (Rev. 08/03/05)
HIPAA Revocation of Authorization to Disclose Health Information (Rev. 03/15/06)
Information Technology Accessibility Complaint Form (Rev. 06/16/09)
Life Insurance Claim Form (Rev. 04/07/10)
Medicare – Pharmacy Direct Claim Form (Rev. 08/08)
Medicare - Disenrollment Letter and Form (Rev. 05/27/09)
Medicare - Pharmacy Coverage Determination - Member (Rev. 2006)
Medicare - Pharmacy Coverage Determination - Physician (Rev. 2006)
Medicare - Vaccine Claim Form (Rev. 10/07)
Member Audit Form (Rev. 04/15/10)
Premium Auto-draft Letter and Form (Rev. 01/22/08)
Verification of Insurance Coverage (VOIC) Form (Rev. 04/22/10)