Forms & Resources
At Health Plans, we take our commitment to your health very seriously. That’s why
we want to be a key source of tools and information to help you be the healthiest you
you can be.
Would you like to:
Forms for Members
Online Access / PHI Disclosure Form
Member Authorization to Obtain PHI
Member Authorization to Release PHI - Care Management Services
Member Authorization to Release PHI - Claims
Transition of Care Request Form
Flexible Spending Account (FSA) & Health Reimbursement Arrangement (HRA)*
FSA Transit/Parking Claim Form
Member Appeal
Member Reimbursements*
Member Reimbursement Form 
submit your request in My Plan
Fitness Reimbursement Form submit your request in My Plan
Weight Loss Reimbursement Form submit your request in My Plan
Travel Reimbursement Form submit your request in My Plan
*Claim and reimbursement forms may not be applicable to all plans. Be sure to check your benefit details in your summary plan description prior to submitting a claim or reimbursement form.
Some forms on this page are in PDF format and require Adobe Reader to open.
