Additional Member Policies |

Additional Forms

 

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

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

 

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

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.

If you have questions please, contact Member Services.