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Frequently Requested Forms

Health Care Information Release

See Accessing Your Medical Records for information about access to and release of your medical records.

• Authorization to Release Health Care Information (PDF)
• Authorization to Release Specially Protected Confidential Information (PDF)
• Revocation of Authorization to Release Health Care Information (PDF)

Transfer of Funds for Monthly Premium Payment

• For Medicare Members (PDF)
• For Individual & Family Plan Members (PDF)

Enrollment and Change Forms for Members

• Patient Registration Information (PDF)
• Transition of Care Guidelines (PDF)
• Transition of Care Coverage Request (PDF)
• Change of Address
• Request an ID Card

Claim Forms

• Accident and Injury Questionnaire (Web form)
• Accident and Injury Questionnaire (PDF)
• Medical & Prescription Drug Claims Form for Member Reimbursement (PDF)
• Coordination of Benefits Questionnaire (Web form)
• Coordination of Benefits Questionnaire (PDF)

Well-Care Questionnaires

• Teens and adults ages 13 to 21 (PDF)
• Women ages 22 to 64 (PDF)
• Men ages 22 to 64 (PDF)
• Adults ages 65 and over (PDF)

Parental Access

• Request for Parental Access (PDF)

Informed Consent

• Authorization to Provide Informed Consent for a Minor (PDF)
• Consent for Blood and Blood Product Transfusion (PDF)
• Consent for Low-Risk, Non-Invasive Procedure (PDF)
• Declaration of Relative Responsible for Health Care of a Minor Patient (PDF)
• Informed Consent for Conscious Sedation (PDF)
• What You Should Know About Informed Consent for a Minor (PDF)