Resource Categories

Important Notices

• Your Rights and Protections Against Surprise Medical Bills

Medical, Dental, and Vision Claim Forms

• Claim Form—Medical
• Claim Form—Dental
• Claim Form—Vision
• International Medical Claim Form
• Claims Fax Cover Sheet
• Claim Appeal Form

Individual & Family Plan Forms

• Coordination of Benefits Questionnaire

Exchange Model Notices & Rights Notifications

• Exchange Model Notice (Coverage Provided)
• Exchange Model Notice (No Coverage Provided)
• Exchange Model Notice Sample Cover Letter
• Women's Cancer Rights Notification
• Children's Health Insurance Program (CHIP) Notice

Medicare Documents & Information

• Employee Notice Packet (Medicare Part D Creditable)
• Employee Notice Packet (Medicare Part D Non-Creditable)
• Medicare Part D Creditable Coverage Notice
• Medicare Part D Non-Creditable Coverage Notice

Provider Pre-Authorization Forms

• Retail Pharmacy Prior Authorization Request Form
• Specialty Pharmacy Request Form
• Formulary Exclusion Prior Authorization Form

Pharmacy Mail-Order, Pre-Authorization Forms & Documents

• Caremark Formulary Exclusions
• Caremark Mail Service Order Form

Security & Privacy Forms & Documents

• HIPAA Authorization Form
• Notice of Privacy Practice
• Sample HIPAA Business Associate Agreement
• Sample HIPAA Business Associate Subcontractor Agreement

Miscellaneous

• Fully Insured with Nationwide - Termination Form
• Self-Funded Program with Nationwide - Termination Form
• Federal Request for Taxpayer Identification Number and Certification (W-9)
• Summary of Benefits and Coverage Uniform Glossary
• SPD Amendment—Virtual Visits
• SPD Amendment—Virtual Visits (MEC)
• Cafeteria Plan Amendment—Mid-Year Election Change
• Travel and Lodge Reimbursement Request Form