File a claim

Download and use these forms to file a claim

Dental PPO claim

Download a dental PPO policy claim form to submit a claim.

Vision PPO claim

Download a vision PPO policy claim form to submit a claim.

HIPPA authorization form

Claim forms already include HIPAA authorization, but you can find a separate form here.

Multi-policy claim

Use this PDF form to submit a claim.

Continuing disability claim

Submit additional information for your on-going disability claim.

Critical illness claim

You can file a critical illness claim if you or a dependent on your policy has been diagnosed with a covered critical illness.

Dental fee schedule claim

Download a dental fee schedule claim form to submit a claim to HealthPlan Services.

Vision fee schedule claim

Download a vision fee schedule claim form to submit a claim to HealthPlan Services.