• Transition of Care Form (PDF)

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)

Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.

• Appointing a Representative (PDF)

We don't want to see you go. Let us improve your experience with our plan. Please call Member Services. We are here to help. If you are still dissatisfied, please fill out and mail the disenrollment form.

• Disenrollment Form (PDF)

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