Member Resources

We are committed to keeping you informed in today’s changing health care climate.

Would you like to:

Print a form?

Order an ID Card?

Access Member Discounts?

Learn About the Healthy Pregnancy Program?

Forms for Members

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Microsoft Word icon Online Access / PHI Disclosure Form

PDF icon Member Authorization to Obtain PHI

PDF icon Member Authorization to Release PHI

Flexible Spending Account (FSA)

PDF icon FSA Claim Form

PDF icon FSA-OTC Claim Form

PDF icon FSA/HRA Direct Deposit Form


Member Appeal

Microsoft Word icon Member Appeal Form

Member Reimbursements

PDF icon Member Reimbursement Form  green starsubmit your request in My Plan

PDF icon Fitness Reimbursement Form  green starsubmit your request in My Plan



PDF icon ElevateHealth Out-of-Area Dependent Coverage Verification Form


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Healthy Pregnancy Program

The Health Plans Healthy Pregnancy Program is a helpful pregnancy planning service available free-of-charge to Dartmouth-Hitchcock medical plan members. Get pregnancy education, support and coordinated care from the first office visit through follow-up. 

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