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Medical Claim Form for Group and Individual & Family Plans

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.

Medicare – Medical – MHN Claim Form & Foreign Claim Questionnaire

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

IFP and Group Member Grievance Form

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

Medicare Supplement Plan Claim Form

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

Hardship Exemption Form

HSA for Life - Enrollment Packet

For enrolling in a Health Savings Account (HSA)

First Health Provider Nomination Form

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

Health Net Life Group Employee/Dependant Enrollment Form

Disabled Dependent Certification Form

Out-of-Pocket Maximum Notification

Large Group Enrollment/Change Form

Small Business Group Employee Enrollment and Change Form (January 2016)

Must be completed and submitted at time of enrollment in order to enroll new employees and existing dependents. Also used for employees and dependents waiving coverage.

Mail Order Pharmacy

CVS Caremark Mail Order Pharmacy

Homescripts Mail Order Pharmacy

Medication Therapy Management

Personal Medication List

Prescription Claims

Prescription Drug Claim Form (Medicare Members)

Prescription Drug Claim Form (Commercial Members)

Prescription Transition Form

Prescription Transition Form (Commercial Members)

Glossary of Health Coverage and Medical Terms

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.

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