Use this form when you want to allow us to share your health information with a person or group:

• PHI Authorization Form (PDF)

Use this form when you want us to cancel or revoke your previous permission to share health information with a person or group:

• PHI Revocation Form (PDF)

Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.

• Appointing a Representative (PDF)

• Member Reimbursement Claim Form - English (PDF)
• Member Reimbursement Claim Form - Spanish (PDF)

• Late Enrollment Penalty (LEP) Reconsideration (PDF)

• Transition of Care Form - English (PDF)
• Transition of Care Form - Spanish (PDF)

Use this form when you want to allow us to share your health information with a person or group:

• PHI Authorization Form (PDF)

Use this form when you want us to cancel or revoke your previous permission to share health information with a person or group:

• PHI Revocation Form (PDF)

• Member Reimbursement Claim Form - English (PDF)
• Member Reimbursement Claim Form - Spanish (PDF)

• Late Enrollment Penalty (LEP) Reconsideration (PDF)