Online Access / PHI Disclosure Form
Member Authorization to Obtain PHI
Member Authorization to Release PHI - Care Management Services
Member Authorization to Release PHI - Claims
Transition of Care Request Form
Member Appeal
Member Reimbursements
Member Reimbursement Form 
submit your request in My Plan
Travel Reimbursement Form submit 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).
Some forms on this page are in PDF format and require Adobe Reader to open.
