Forms for Members
Download and print commonly used forms. All forms are in PDF format. Download Acrobat Reader.
| Dental Claim Form | Use this form to file a claim for dental services | Download Form |
| Medical Claim Form | Use this form to file a claim for medical services, such as office visits, physical therapy, laboratory service, and radiology services such as X-rays. | Download Form |
| Prescription Drug Claim Form | If your plan includes the prescription coverage and you are unable to have a prescription claim filed by the pharmacy, use this form to submit a claim for prescription benefits. | Download Form |
| Vision Claim Form | If your plan includes vision care, use this form to file a claim for services from providers who are out of network. | Download Form |
| Cancel Spouse or Dependent Coverage | This form notifies us to cancel existing coverage for a spouse or dependent. | Download Form |
| Change Notification Form | Complete this form if your name changes through marriage or other event, or if your mailing address changes. | Download Form |
| Continuity of Care | This form is used to request Continuity of Care as outlined under No Surprises Act. | |
| Dental Continuation of Care Request Form | This form contains important information about your dental health care provider’s status. | |
| HIPAA Authorization to Release Information | This form is used for a participant to authorize a release of personal health information including medical, FSA and/or HRA claims, enrollment and reimbursements. | Download Form |
| Request for Cancellation | Use this form to cancel your coverage if your ID number begins with ZSD or ZSM. | Download Form |
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