Commonly Used Forms

Commonly Used Member Forms

These forms are in Adobe Acrobat (.pdf) format. Get the Acrobat reader here.

• Member/Subscriber Claim Form 
• Member/Subscriber Claim Form (For Medicare Only)
• HIPAA - General Release of Information Form: Member/Subscriber 
• Advance Directives Form
• Injury Questionnaire Form
• Level 1 Appeal Form
• Grievance Form
• Transition of Care Services Form 

Individual Health Plan: Member Plan Change Forms 

• Termination:  When you need to terminate your Individual Plan coverage or a dependant from your plan.
  Individual Plan Voluntary Member Termination Form
   
• Add or Move a Dependant: When you are requesting to add or move a dependant to or from your current benefits.
  Individual Plan Member Add Dependent Form and Medical Form 

• Health Savings Account Authorization Form: For Savvy100 members only.

Presbyterian HSA Authorization Savvy100 Form

 Individual Health Plan: Member Reimbursement Forms  

For Individual PresMetro, PresSolo, and Select members requesting reimbursement for eligible services such as alternate therapies, dental treatment or diagnostic devices, please select the appropriate form below.  

• PresSolo Plan: PresSolo Unique Services Reimbursement Form
   
• Select Plan: Select Plan Unique Services Reimbursement Form
   
• PresMetro Plan: PresMetro Unique Services Reimbursement Form