Public Entity Members

HIPAA Privacy

• Authorization to Release Protected Health Information
• Request for Restriction on Use and Disclosure of Health Care Information and/or Confidential Communication
• Member Record Amendment/Correction

Subscriber Forms

• Notice of Special Enrollment Rights

UMR

• Other Insurance Coverage Questionnaire
• Medical Claim Form
• Vaccine Reimbursement Form (Non-network)
• Reimbursement for Travel and Lodging Associated with a Transplant

Other Plans

• Delta Dental Claim Form
• Delta Dental Self-Report Form
• ESI Claim Form
• NVA Claim Form