Have an Enrollment need? Call us at 1-833-510-4727 (Relay 711). Learn More.
Member Materials and Forms
Member Resources
Many of our member resources, such as the member handbook and forms, can be found by logging into your online member account. Click Login to create an account and access a wide array of resources!
Member Handbook
Reference Materials
- Transparency Notice 2020
- Transparency Notice 2019
- Statement of Non-Discrimination
- Find a Provider Guide (PDF)
- Preventive Services Guide (PDF)
- Where to go for Care
- Dr. Office Visit Checklist (PDF)
Forms
- Authorization to Disclose Health Information Form (PDF)
- Revocation of Authorization to Disclose Health Information Form (PDF)
- Grievance & Complaint Form (PDF)
- Member Reimbursement Medical Claim Form (PDF)
- Prescription Claim Reimbursement Form (PDF)
- Donor Transplant Travel Reimbursement Form (PDF)
- Recipient Transplant Travel Reimbursement Form (PDF)
- Member Transplant Travel Reimbursement Policy (PDF)
- PA Insurance Department Complaint Form