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Medical Claim Form for Group

• Medical Claim Form – English (PDF)
• Medical Claim Form – En Español (Spanish) (PDF)

Complete the claim form for each member submitting bills for reimbursement of covered services. To avoid any delay, be sure to answer each question completely. PLEASE ATTACH FULLY ITEMIZED BILLS AND PROOF OF PAYMENT.

Medicare – Medical – MHN Claim Form & Foreign Claim Questionnaire

• MHN Claim Form & Foreign Claim Questionnaire – English (PDF)

Group Member GRIEVANCE FORM

• GRIEVANCE FORM – English (PDF)
• GRIEVANCE FORM – Chinese Mandarin - 中文 (PDF)
• GRIEVANCE FORM – En Español (Spanish) (PDF)

Please explain in detail the circumstances that led to your dissatisfaction with Health Net. Please include the original copy of any claims or bills received which are related to your issue.

Dental Claim Form

• Dental Claim Form – English (PDF)

Medicare Supplement Plan Claim Form

• Medicare Supplement Plan Claim Form

Out-of-Network Vision Claim Form (non-Medicare)

• Out-of-Network Vision Claim Form – English (PDF)

HMO Enrollment Application

• HMO Enrollment Application - English (PDF)
• HMO Enrollment Application - En Español (Spanish) (PDF)
• HMO Enrollment Application - Chinese Mandarin - 中文 (PDF)
• HMO Enrollment Application - Korean - 한국어 (PDF)

HSP Enrollment Application

• HSP Enrollment Application - English (PDF)
• HSP Enrollment Application - En Español (Spanish) (PDF)
• HSP Enrollment Application - Chinese Mandarin - 中文 (PDF)

PPO Enrollment Application

• PPO Enrollment Application - English (PDF)
• PPO Enrollment Application - En Español (Spanish) (PDF)
• PPO Enrollment Application - Chinese Mandarin - 中文 (PDF)
• PPO Enrollment Application - Korean - 한국어 (PDF)

EPO Enrollment Application

• EPO Enrollment Application - English (PDF)
• EPO Enrollment Application - En Español (Spanish) (PDF)
• EPO Enrollment Application - Chinese Mandarin - 中文 (PDF)
• EPO Enrollment Application - Korean - 한국어 (PDF)

Hardship Exemption Form

• Hardship Exemption Form - English (PDF)

HSA for Life - Enrollment Packet

• HSA for Life - Enrollment Packet - English (PDF)

For enrolling in a Health Savings Account (HSA)

Department of Managed Health Care (DMHC)

• Right to Submit Request for Review of Cancellation, Rescission, or Nonrenewal of Your Plan Contract, Enrollment, or Subscription - English (PDF)
• Request for Review of Cancellation, Rescission, or Nonrenewal of Plan Contract - English (PDF)

Payment Options

• Payment Options - English (PDF)
• Payment Options - En Español (Spanish) (PDF)
• Payment Options - Chinese Mandarin - 中文 (PDF)

First Health Provider Nomination Form

• First Health Provider Nomination Form - English (PDF)

You can save a lot by using a doctor who participates in the First Health Network. That's why we make it easy for you to nominate him or her to join.

Continuity of Care Assistance Request Form

• Continuity of Care Assistance Request Form - English (PDF)
• Continuity of Care Assistance Request Form - En Español (Spanish) (PDF)

Health Net Life Group Employee/Dependent Enrollment Form

• Employee/Dependent Enrollment Form - English (PDF)
• Employee/Dependent Enrollment Form - En Español (Spanish) (PDF)
• Employee/Dependent Enrollment Form - Chinese Mandarin - 中文 (PDF)

Accident Waiver Deductible Request Form

• Accident Waiver Deductible Request Form - English (PDF)

This form must be received by Health Net Life within 60 days of the accident date of service. Please refer to your Policy for details on the accident waiver.

Disabled Dependent Certification Form

• Disabled Dependent Certification Form - English (PDF)

Out-of-Pocket Maximum Notification

• Out-of-Pocket Maximum Notification - English (PDF)

Large Group Enrollment/Change Form

• Large Group Enrollment/Change Form - English (PDF)
• Large Group Enrollment/Change Form - En Español (Spanish) (PDF)
• Large Group Enrollment/Change Form - Chinese Mandarin - 中文 (PDF)

Authorization For Disclosure of PHI

• Authorization For Disclosure of PHI - English (PDF)
• Authorization For Disclosure of PHI - En Español (Spanish) (PDF)
• Authorization For Disclosure of PHI - Chinese Mandarin - 中文 (PDF)
• Authorization For Disclosure of PHI - Korean - 한국어 (PDF)

Glossary of Health Coverage and Medical Terms

• Glossary of Health Coverage and Medical Terms - English (PDF)
• Glossary of Health Coverage and Medical Terms - En Español (Spanish) (PDF)
• Glossary of Health Coverage and Medical Terms - Chinese Mandarin - 中文 (PDF)
• Glossary of Health Coverage and Medical Terms - Navajo - Diné bizaad (PDF)
• Glossary of Health Coverage and Medical Terms - Korean - 한국어 (PDF)

Health insurance companies and group health plans are required to make available a uniform glossary of health coverage and medical terms commonly used in plan documents. The Uniform Glossary is meant to help the consumer understand some of the most common language used in health insurance documents. Please log in to request a hardcopy of the document by mail.