How to View and Download

To view or download a file, click the desired language link. The PDF file will open in a new window or tab of your browser. From there, you can also download or print the file. 

Medical Claim Form for Group

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.

Medicare – Medical – MHN Claim Form & Foreign Claim Questionnaire

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)

Department of Managed Health Care (DMHC)

Payment Options

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

Accident Waiver Deductible Request Form

This form must be received by Health Net Life within 60 days of the accident date of service. Please refer to your Policy for details on the accident waiver.

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.

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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