Important Forms

File a claim. Order prescription drugs. All the forms you need for communicating with the State Health Plan are listed below.

Enroll in a plan
Learn how to enroll, including instructions and application forms.

Health Screening Results Form
This form should be completed by a medical professional to assist you in completing your health assessment, which can be completed online using the Personal Health Portal or by calling 800-817-7044.

Update Your Information
Change your name or address, or add and remove dependents.

Prior Health Coverage Information
If you had coverage under a previous plan, perhaps from a previous employer, use this form to receive credit against the waiting period for pre-existing conditions.

Authorization to Share Information
Give someone permission (as required by law) to access your health information. Please use the appropriate form based on the health plan in which the member is enrolled.

  • Members enrolled in the Traditional 70/30 Plan, Enhanced 80/20 and CDHP click here for the appropriate form.
  • Members enrolled in the Humana Group Medicare Advantage Plans click here for the appropriate form.
  • Members enrolled in the Group United Healthcare Medicare Advantage Plans click here for the appropriate form.

Authorize a Representative – Appeals
Use this form to allow a third party to appeal a denied claim or denied certification on your behalf.

Notice of Privacy Practices
Learn how medical information about you may be used and disclosed and how you can get access to this information.

Coverage Request for Incapacitated Dependent – If you have a child over age 26 who is eligible as a mentally or physically incapacitated dependent, complete this form.

Request Reimbursement
Access various types of claim forms.

Appeal a Decision
Dispute the way a claim was paid.

Order Prescription Drugs
Request that your prescription be filled by mail.

Special Care Pharmacy Fax Form
Request a specialty medication through Medco.

Flexible Benefit Plan (Section 125) Rejection Form
Learn how to opt out of the Flexible Benefit Plan, IRS Section 125.

Subrogation – Third Party Recovery
Recover medical expenditures incurred by the State Health Plan where a third party is liable.

Reimburse the State
Pursue claims paid by the State Health Plan where a third party is liable.

HIPAA Compliance Questionnaire
Questionnaire for State Health Plan vendors.

Continuation of Coverage Rights Under COBRA
This explains COBRA continuation rights when health benefit plan coverage would otherwise end because of a life event known as a "qualifying" event.

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