Types of forms
Use these forms to request a change to your current policy, such as name changes, deductible amounts, dependent status and more.
- Change form
Make changes to existing membership. Send this form to your Human Resources office.
A covered person or an authorized representative can submit written proof of any service, supply, prescription drug, test, equipment or other treatment up to 180 days after the service. In most cases, your healthcare provider will file claims directly with us for services provided. If that does not occur, you may submit the claim directly to us.
Send the completed claim form and written proof of services to the contact information listed on the claim form. For more information, call the customer service number on the back of your member ID card.
Important: Your submission may be returned if it does not comply with our filing and coding policies and procedures. You may request a copy of the claim coding policies and procedures from us or the service provider.
- Dental claim formFor dental claims if your group has dental benefits.
- International claim form
- Medical claim form
- Prescription claim form
To make sure eligible claims are paid quickly, please complete and submit this form.
- Prescription claim form - Spanish
These printable forms help you to efficiently exercise your privacy rights. Simply print, complete and send them to the Privacy Office (listed on the form) so we can process your request promptly with the necessary information.
- Request for accounting
You have the right to request a list of any disclosures we have made of your protected health information for purposes other than payment or healthcare operations.
- Request for confidential communications
You have the right to request that we keep communications with you confidential and communicate in an alternate manner.
- Request for restrictions
You have the right to request that we restrict the use of your protected health information for payment and healthcare operations.
- Request to correct or amend record
You have the right to request that any information we created about you be amended if you believe that it is incorrect.
- Request to inspect health information
You have the right to inspect or get a copy of records we maintain about you in a designated record set and which we used to make a decision about you.
- Request for Confidential Communication (HIPAA)
- Prescription reimbursement claim form
- Prescription reimbursement claim form - Spanish
- Prior authorization form for prescription drugsInformation contained in this form is protected health information under HIPAA. Complete the requested information, sign and date the form. Fax signed forms to CVS/Caremark at 855-245-2134 for prior authorization, step therapy and quantity limit requests. Contact CVS/Caremark at 855-582-2022 with questions regarding the step therapy, prior authorization and the quantity limit review process. For Non-Formulary Exception requests, fax the form to 501-378-6980. For Non-Formulary Exception request questions, contact 501-378-3392.
- Prescription mail service order form
- Appeal filing form
This form may only be used for the following groups: ARcare, Arkansas Children’s, Inc., Arkansas College of Health Education (ACHE), Bad Boy Mowers , LLC, Bryce Corporation, Central Arkansas Radiation Therapy Institute, Inc., City of Marion, CommonSpirit Health, E. Ritter Communications Holdings, LLC, Farmer's Bank and Trust, First Bank Corporation, FutureFuel, Jefferson Hospital Association, Inc., Klaasmeyer, Lexicon, Inc., LifePlus, Little John Transport, Nucor Corporation, Revolution Sustainable Solutions, LLC, Suzano Packaging, LLC, The Stephens Group, University of Central Arkansas, and Water Tech.
- Authorization for release of information
Request authorization for someone else to act on your behalf regarding your medical coverage.
- Cancel authorized representative appointment form
- Continuity of care form
- Designation of authorized appeal representative
- Designation of authorized appeal representative - Non-ERISA
- Incapacitated dependent form
This form is to be submitted for a request of continuation of coverage for dependents with a mental or physical handicap that have exceeded the student age.
- Other insurance/Coordination of Benefits (COB)