Forms

Medical Claim Form for Group

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

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)

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.