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Materials and forms

Here, you’ll find the info and forms you need to get the most from your plan.

Member handbook

Member handbook English (PDF)

Member handbook Spanish (PDF)

Member materials

New member newsletter English (PDF)

New Member newsletter Spanish (PDF)

Extra Benefits English (PDF)

Extra Benefits Spanish (PDF)

Forms

Authorization to Release Protected Health Information (PHI) English (PDF)

Authorization to Release Protected Health Information (PHI) Spanish (PDF)

Authorization to Release Psychotherapy Notes English (PDF)

Authorization to Release Psychotherapy Notes Spanish (PDF)

Protected Health Information (PHI) Access Request English (PDF)

Protected Health Information (PHI) Access Request Spanish (PDF)

Request for an Accounting of Disclosures of Protected Health Information (PHI) English (PDF)

Request for an Accounting of Disclosures of Protected Health Information (PHI) Spanish (PDF)

Removal of Authorization Previously Given English (PDF)

Removal of Authorization Previously Given Spanish (PDF)

Fraud, waste and abuse form