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Member Forms

General Instructions:

  • Each form here contains a brief description to help you determine which one(s) you may need to use.
  • Please read each form carefully as additional instructions may apply
  • Most of our forms are available in multiple formats - please choose which format works best for you.
  • Many of our PDF forms allow electronic signatures. For information on how to sign a PDF form electronically, click here
  • Please note that if you send us information, such as a completed form, through unsecured email (for example, Gmail, Yahoo Mail, Hotmail, etc.), we cannot guarantee that your protected health information (PHI) is secure. Depending on what you need to send us, we provide other secure methods of submission, such as our member portal and DocuSign. Please choose the submission method that you are most comfortable with.

Member Forms:

  • Over-the-Counter (OTC) COVID Test Reimbursement Claim Form  ***Please read the following before filling out this form.***
    Most employers are covering OTC COVID test reimbursement under the pharmacy plan, not under the medical plan. You can find your pharmacy plan's Customer Support phone number on the back of your member ID card. In order to prevent delays, we strongly recommend that you check with your pharmacy plan before submitting a reimbursement request to us, your medical plan administrator. If you know or believe that OTC COVID test reimbursement is covered under your medical plan, however, please use this form: Complete Online or Download pdf 
  • Member Reimbursement Claim Form Complete Online or Download pdf   Do not use this form to submit for reimbursement of COVID-19 over-the-counter tests purchased on or after Jan 15, 2022
    Request reimbursement for medical, dental, or vision services that were rendered by a provider who “doesn’t accept [your] insurance” or in other words, is out of network. Click here to read more about submitting a claim. 
  • Member Travel Reimbursement Claim Form ***Please read the following before filling out this form. ***You may be eligible for reimbursement from your Health Plan for expenses you incurred from traveling for an eligible medical procedure located outside of your state of residence. Before you submit this form, please check with your Health Plan if you have this travel benefit available to you. Once you’re ready to fill out this form: Complete Online or Download pdf 
  • Authorization to Disclose Protected Health Information (PHI) Form Complete Online or Download pdf
    Use this form to authorize the release of your Protected Health Information (PHI) to others such as family members, specific providers/facilities, legal representation, etc.
  • Other Health Insurance Coverage Form Complete Online or Download pdf 
    Let us know of additional health insurance coverage for yourself or someone on your plan outside of HMA. We refer to this as Coordination of Benefits (COB). Click here to read more about COB.
  • Privacy Complaint Form Complete Online or Download pdf 
    Use this form if you believe the Group Health Plan (GHP) or HMA acting on behalf of your GHP, has failed to protect your or someone else’s privacy or has violated privacy policies.
  • Request for Confidential Communication Form Complete Online or Download pdf
    Use this form to ask that we not share information with the person who pays for your insurance. This form is generally used if releasing your Protected Health Information (PHI) to the plan subscriber (the person whose name appears on your ID card) could affect your safety. 
  • Member Appeal Submission Form Complete Online or Download pdf
    Use this form if you disagree with our decision to deny (whether in whole or in part) or apply any of the following: copayments, deductibles, coinsurance, eligibility, benefits, or pre-authorizations.  

Looking for COBRA forms? Find them here.