Forms

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.

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.

Behavioral Health (MHN) Claim Form

Behavioral Health (MHN) Claim Form – English (PDF)

Behavioral Health (MHN) Foreign Claim Form & Questionnaire

Behavioral Health (MHN) Foreign Claim Form & Questionnaire – English (PDF)

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.

Dental Claim Form

Dental Claim Form – English (PDF)

Out-of-Network Vision Claim Form

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

Health Net Life Group Enrollment and Change Form for Dependents

Dependent Enrollment and Change Form – English (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)

Disabled Dependent Certification Form

Disabled Dependent Certification Form – English (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

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

Prescription Transition Form

• Prescription Transition Form – English (PDF)
• Prescription Transition Form – 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.