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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.

Group Member GRIEVANCE FORM

• Commercial GRIEVANCE FORM – English (PDF)
• Commercial GRIEVANCE FORM – En Español (Spanish) (PDF)
• Commercial GRIEVANCE FORM – Chinese (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.

Continuity of Care Assistance Request Form

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

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

• 2022 – Employee Enrollment and Change Form – English (PDF)
• 2022 – Employee Enrollment and Change Form – En Español (Spanish) (PDF)
• 2022 – Employee Enrollment and Change Form – 中文 (Chinese) (PDF)

Mail Order Pharmacy

• CVS Caremark Mail Order Pharmacy – English (PDF)
• CVS Caremark Mail Order Pharmacy – En Español (Spanish) (PDF)

Prescription Claims

• Prescription Drug Claim Form (Medicare Members) – English (PDF)
• Prescription Drug Claim Form (Commercial Members) – English (PDF)
• Prescription Drug Claim Form (Commercial Members) – En Español (Spanish) (PDF)

Prescription Transition Form

• Prescription Transition Form (Commercial Members) – English (PDF)
• Prescription Transition Form (Commercial Members) – En Español (Spanish) (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.