Frequently Requested Forms

Medical Record Access
and Health Care Information Release

How to Transfer and Get Copies of Your Medical Records

• Authorization to Disclose (Release) Health Care Information (PDF)
• Revocation of Authorization for a Release of Health Care Information by Group Health (PDF)

Parental Access

• Request for Parental Access to Child's Online (MyGroupHealth) Medical Record (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)
• Medicare Part D Reimbursement Form for Prescription Drugs (PDF)

Claim Forms

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

Applied Behavioral Analysis (ABA)

Information about ABA therapy for autism

• Member Reimbursement Form for Applied Behavioral Analysis (PDF)

Neurodevelopmental Therapies

Information about neurodevelopmental therapies

• Member Reimbursement Form for Neurodevelopmental Therapies (PDF)
• Member Reimbursement Form Instructions (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 for Members to use these online forms. This helps us process your request more quickly. (To log in, you have to be registered.)

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 in to MyGroupHealth for Members. (To log in, you have to be registered.)