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PHONE HOTLINE: (855) 378-6777
ENROLL NOW
PHONE HOTLINE: (855) 378-6777
ENROLL NOW
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MEMBER FORMS

 

 

Member Forms

Click to access or download each.

Add-On Family Form Add-on a new family member. Get Started BMI Verification

Measurements for height, and weight taken within the last 30 days are acceptable.

 Get Started Extra Impact Application Special assistance for Impact members in need. Get Started Health & Wholeness Credit expense form Submit expenses for the Health & Wholeness Credit for processing. Get Started Medical expense form Submit medical expenses for processing. Get Started Medical expense form - out of country Submit medical expenses for processing that were incurred outside the United States. Get Started PRA Change Request Requests may be made annually within 30 days of membership date. Get Started Provider Outreach Request
  • Available only after an appointment is scheduled.
  • This form is for Provider Visits only.
  • Not applicable for Senior Program
 Get Started Request member Card Submit a request for a new member card.  Get Started
pre-ELIGIBILITY

Providers, please request a pre-eligibility review by either calling (855) 378-6777 or completing the online form.

Get Started Online ->

Pre-eligibility submission is only for the following:

  1. Cancer Treatment
  2. Elective Cardiac Procedures
  3. Non-emergency inpatient/outpatient surgery
  4. Organ/Tissue Transplant Services
  5. Maternity
  6. Imaging: MRIs and Nuclear Imaging (excluding CT Scans and xrays)

**Please be advised that pre-eligibility is required only for non-emergent procedures/medical expenses. If member requires emergent services, please proceed without submitting a pre-eligibility request and eligibility will be determined post-procedure

  
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