Use this form when you want to allow us to share your health information with a person or group:

• PHI Authorization Form (PDF)

Use this form when you want us to cancel or revoke your previous permission to share health information with a person or group:

• PHI Revocation Form (PDF)

• Member Reimbursement Claim Form - English (PDF)
• Member Reimbursement Claim Form - Spanish (PDF)

• PCP Change Request Form - English (PDF)
• PCP Change Request Form - Spanish (PDF)

• Late Enrollment Penalty (LEP) Reconsideration (PDF)

Use this form when you want to allow us to share your health information with a person or group:

• PHI Authorization Form - English (PDF)

Use this form when you want us to cancel or revoke your previous permission to share health information with a person or group:

• PHI Revocation Form - English (PDF)
• PHI Revocation Form - Spanish (PDF)

• Member Reimbursement Claim Form - English (PDF)
• Member Reimbursement Claim Form - Spanish (PDF)

• PCP Change Request Form - English (PDF)
• PCP Change Request Form - Spanish (PDF)

• Late Enrollment Penalty (LEP) Reconsideration (PDF)