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Medical Claim Form for Group and Individual & Family Plans

• Medical Claim Form – English (PDF) 542kB
• Medical Claim Form – Spanish – Español (PDF) 502kB

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.

Proof of payment includes:

• Copy of cancelled check (front and back) or online bank statement
• Copy of credit card statement or bank statement

NOTE:

• Proof of payment on a Dr.'s prescription form is not acceptable.
• Invoices are not acceptable forms of proof of payment.

Non-Medicare – Behavioral Health (MHN) – Claim Form

Behavioral Health (MHN) – Claim Form – English (PDF) 1MB 12/18/17

Group Member Grievance Form

• Grievance Form – English (PDF) 18kB 11/06/13
• Grievance Form – Chinese Mandarin – 中文 (PDF) 116kB 11/06/13
• Grievance Form – Spanish – Español (PDF) 19kB 11/06/13

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.

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

Out-of-Network Vision Claim Form – English (PDF) 512kB 06/27/17

Continuity of Care Assistance Request Form

• Continuity of Care Assistance Request Form – English (PDF) 524kB 01/17/18
• Continuity of Care Assistance Request Form – Spanish – Español (PDF) 572kB 01/17/18

Out-of-Pocket Maximum Notification

Out-of-Pocket Maximum Notification – English (PDF) 92kB 01/30/14

Mail Order Pharmacy

CVS Caremark Mail Order Pharmacy

• CVS Caremark Mail Order Pharmacy – English (PDF) 147kB 11/29/17
• CVS Caremark Mail Order Pharmacy – Spanish – Español (PDF) 151kB 11/29/17

Prescription Claims

Prescription Drug Claim Form (Medicare Members)

• Prescription Drug Claim Form (Medicare Members) – English (PDF) 144kB 02/01/19
• Prescription Drug Claim Form (Medicare Members) – Spanish – Español (PDF) 144kB 02/01/19

Prescription Drug Claim Form (Commercial Members)

• Prescription Drug Claim Form (Commercial Members) – English (PDF) 3.2MB 09/29/17
• Prescription Drug Claim Form (Commercial Members) – Spanish – Español (PDF) 3.2MB 09/29/17

Prescription Transition Form

Prescription Transition Form (Commercial Members)

• Prescription Transition Form (Commercial Members) – English (PDF) 464kB 05/15/18
• Prescription Transition Form (Commercial Members) – Spanish - Español (PDF) 463kB 05/15/18

Authorization For Disclosure of PHI

• Authorization For Disclosure of PHI – English (PDF) 568kB 05/29/19
• Authorization For Disclosure of PHI – Spanish – Español (PDF) 558kB 05/29/19
• Authorization For Disclosure of PHI – Chinese Mandarin – 中文 (PDF) 769kB 05/29/19
• Authorization For Disclosure of PHI – Korean – 한국어 (PDF) 671kB 05/29/19

Glossary of Health Coverage and Medical Terms

• Glossary of Health Coverage and Medical Terms – English (PDF) 117kB 07/22/16
• Glossary of Health Coverage and Medical Terms – Spanish - Español (PDF) 138kB 07/22/16
• Glossary of Health Coverage and Medical Terms – Chinese Mandarin - 中文 (PDF) 447kB 07/22/16
• Glossary of Health Coverage and Medical Terms – Navajo – Diné bizaad (PDF) 230kB 07/22/16
• Glossary of Health Coverage and Medical Terms – Korean – 한국어 (PDF) 1.2MB 07/22/16

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.