Frequently Requested Forms

Medical Record Access
and Health Care Information Release

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

• Request for Parental Access to Child's Online (MyGroupHealth) Medical Record (PDF)
• Authorization to Release Health Care Information (PDF)
• Authorization for the Release of Specially Protected Confidential Information (PDF)
• Revocation of Authorization for a Release of Health Care Information by Group Health (PDF)

Transfer of Funds for Monthly Premium Payment

• For Clear Care® Medicare Advantage Members (PDF)
• For Individual and Family Plan Members (PDF)

Enrollment and Change Forms

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

Pharmacy Forms

• Drug Formulary Exception Request*
• New Prescription Order (PDF)
• Refill Prescription Order (PDF)**
• Prescription Transfer (PDF)**
• Medical & Prescription Drug Claims for Member Reimbursement (PDF)

Claim Forms

• Accident and Injury Questionnaire*
• Accident and Injury Incident Questionnaire (PDF)
• Medical & Prescription Drug Claims for Member Reimbursement (PDF)
• Coordination of Benefits Questionnaire*
• Coordination of Benefits Questionnaire (PDF)

Well-Care Questionnaires

These questionnaires are to be filled out before a well-care visit, also called preventive care.

• Children ages 5 to 9 (PDF)
• Preteens ages 10 to 12 (PDF)
• Teens ages 13 to 17 (PDF)
• Young adults ages 18 to 21 (PDF)
• Women ages 22 to 64 (PDF)
• Men ages 22 to 64 (PDF)
• Adults ages 65 and older (PDF)

Informed Consent Forms

• 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)

* To protect the security of personal information, you must log in to MyGroupHealth to use these forms. Online forms help us process your information or request more quickly.

If you don't want to log in, in some cases, there is also a PDF version of the same form. However, you must print the PDF, fill it out, and send it via postal mail. For security reasons, PDFs cannot be submitted as e-mail attachments.

** You can refill and transfer prescriptions online by logging into MyGroupHealth for Members. You must have an enhanced account to use these online services.