Forms & Resources

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Authorizations

PDF icon Online Access / PHI Disclosure Form

PDF icon Member Authorization to Obtain PHI

PDF icon Member Authorization to Release PHI - Care Management Services

PDF icon Member Authorization to Release PHI - Claims

PDF icon Transition of Care Request Form

Member Appeal

PDF icon Member Appeal Form

Member Reimbursements

PDF icon Standard Medical Claim Form

PDF icon Member Reimbursement Form  green starsubmit your request in My Plan

PDF icon Travel Reimbursement Form  green starsubmit your request in My Plan


 

Pharmacy

Looking for a pharmacy form? Call Southern Scripts, your pharmacy benefit plan manager, at 800-710-9341, weekdays from 8am-8pm (ET).

 

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