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Member Forms

General Instructions:

  • 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:

  • 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.
     
  • 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.  
     
  • Member Reimbursement Claim Form Complete Online or Download pdf 
    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. 
     
  • 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.