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Member materials and forms

Here, you’ll find the info and forms you need to get the most from your plan.

Materiales para miembros

 

Integrative health services member handbook ― English (PDF) | Spanish (PDF)

 

Mental health and substance use treatment services handbook ― English (PDF) | Spanish (PDF)

 

Provider and pharmacy directory (PDF)

 

Clinical Practice Guidelines (PDF)

Formularios

 

Submit a Grievance (PDF)

 

Member Appeal Form (PDF)

 

Authorization to release protected health information (PHI) (PDF)

 

Authorization to release psychotherapy notes (PDF)

 

Fraud, waste and abuse form

 

Grievance and appeal form

 

Member advisory committee application ― English (PDF) | Spanish (PDF)

 

Notification of pregnancy (PDF)

 

Transition of care form ― English (PDF) | Spanish (PDF)

 

Notice of Privacy Practices  ― English (PDF) | Spanish (PDF)

 

Protected health information (PHI) access request form GR-69238-1 — English | Spanish

 

Request for an Accounting of Disclosures of Protected Health Information (PHI) GR-69239-1 — English | Spanish

 

Protected health information (PHI) release form GR-69126-1 — English | Spanish

 

Authorization to release psychotherapy notes GR-69127-1 — English | Spanish

 

Removal of Authorization Previously Given to Aetna GR-69240-1 — English | Spanish

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