Health Plans Inc. | Member Resource Center

Forms & Resources

At Health Plans, we take our commitment to your health very seriously. That’s why
we want to be a key source of tools and information to help you be the healthiest you
you can be.

Would you like to:

Print a form?

Order an ID Card?

Forms for Members

Authorizations

Online Access / PHI Disclosure Form

Member Authorization to Obtain PHI

Member Authorization to Release PHI - Care Management Services

Member Authorization to Release PHI - Claims

Transition of Care Request Form

Flexible Spending Account (FSA) & Health Reimbursement Arrangement (HRA)*

FSA Claim Form

HRA Claim Form

FSA Transit/Parking Claim Form

FSA/HRA Direct Deposit Form

Member Appeal

Member Appeal Form

Member Reimbursements*

Standard Medical Claim Form

Standard Dental Claim Form

Member Reimbursement Form submit your request in My Plan

Short Term Disability Form

Fitness Reimbursement Form submit your request in My Plan

Weight Loss Reimbursement Form submit your request in My Plan

Travel Reimbursement Form submit your request in My Plan

*Claim and reimbursement forms may not be applicable to all plans. Be sure to check your benefit details in your summary plan description prior to submitting a claim or reimbursement form.

Some forms on this page are in PDF format and require Adobe Reader to open.

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Forms & Resources

Forms for Members