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Medical Claim Form for Group and Individual & Family Plans

• Medical Claim Form – English (PDF) 542kB 12/19/17
• Medical Claim Form – Spanish – Español (PDF) 502kB 12/19/17

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

• MHN Claim Form & Foreign Claim Questionnaire – English (PDF) 1MB 12/18/17

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

• Behavioral Health (MHN) – Claim Form – English (PDF) 1MB 12/18/17

IFP and Group Member Grievance Form

• Grievance Form – English (PDF) 18kB 11/06/13
• Grievance Form – Chinese Mandarin – 中文 (PDF) 116kB 11/06/13
• Grievance Form – Spanish – Español (PDF) 19kB 11/06/13

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) 2.8MB 01/09/09

Medicare Supplement Plan Claim Form

• Medicare Supplement Plan Claim Form – English (PDF) 26kB 11/26/07

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

• Out-of-Network Vision Claim Form – English (PDF) 512kB 06/27/17

Hardship Exemption Form

• Hardship Exemption Form – English (PDF) 178kB 01/21/16

HSA for Life - Enrollment Packet

• HSA for Life - Enrollment Packet – English (PDF) 124kB 01/29/19

For enrolling in a Health Savings Account (HSA)

First Health Provider Nomination Form

• First Health Provider Nomination Form – English (PDF) 636kb 03/09/17

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) 524kB 01/17/18
• Continuity of Care Assistance Request Form – Spanish – Español (PDF) 572kB 01/17/18

Health Net Life Group Employee/Dependant Enrollment Form

• Employee/Dependant Enrollment Form – English (PDF) 938kB 07/25/17
• Employee/Dependant Enrollment Form – Spanish – Español (PDF) 549kB 07/25/17
• Employee/Dependant Enrollment Form – Chinese Mandarin – 中文 (PDF) 932kB 09/19/11

Disabled Dependent Certification Form

• Disabled Dependent Certification Form – English (PDF) 67kB 05/09/19

Out-of-Pocket Maximum Notification

• Out-of-Pocket Maximum Notification – English (PDF) 92kB 01/30/14

Large Group Enrollment/Change Form

• Large Group Enrollment/Change Form – English (PDF) 716kB 08/29/18
• Large Group Enrollment/Change Form – Spanish – Español (PDF) 528kB 08/29/18
• Large Group Enrollment/Change Form – Chinese Mandarin – 中文 (PDF) 4.9MB 10/04/18

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

• Small Business Group Employee Enrollment and Change Form – English (PDF) 941kB 03/01/16
• Small Business Group Employee Enrollment and Change Form – Spanish – Español (PDF) 3.7MB 02/09/17
• Small Business Group Employee Enrollment and Change Form – Chinese Mandarin – 中文 (PDF) 1.1MB 03/03/17
• Small Business Group Employee Enrollment and Change Form – Korean – 한국어 (PDF) 902kB 03/10/17

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

• CVS Caremark Mail Order Pharmacy – English (PDF) 147kB 11/29/17
• CVS Caremark Mail Order Pharmacy – Spanish – Español (PDF) 151kB 11/29/17

Homescripts Mail Order Pharmacy

• Homescripts Mail Order Pharmacy – English (PDF) 550kB 11/29/17
• Homescripts Mail Order Pharmacy – Spanish – Español (PDF) 627kB 11/29/17

Medication Therapy Management

Personal Medication List

• Personal Medication List – English (PDF) 594kB 12/13/16

Prescription Claims

Prescription Drug Claim Form (Medicare Members)

• Prescription Drug Claim Form (Medicare Members) – English (PDF) 144kB 02/01/19
• Prescription Drug Claim Form (Medicare Members) – Spanish – Español (PDF) 144kB 02/01/19

Prescription Drug Claim Form (Commercial Members)

• Prescription Drug Claim Form (Commercial Members) – English (PDF) 3.2MB 09/29/17
• Prescription Drug Claim Form (Commercial Members) – Spanish – Español (PDF) 3.2MB 09/29/17

Prescription Transition Form

Prescription Transition Form (Commercial Members)

• Prescription Transition Form (Commercial Members) – English (PDF) 464kB 05/15/18
• Prescription Transition Form (Commercial Members) – Spanish - Español (PDF) 463kB 05/15/18

Authorization For Disclosure of PHI

• Authorization For Disclosure of PHI – English (PDF) 568kB 05/29/19
• Authorization For Disclosure of PHI – Spanish – Español (PDF) 558kB 05/29/19
• Authorization For Disclosure of PHI – Chinese Mandarin – 中文 (PDF) 769kB 05/29/19
• Authorization For Disclosure of PHI – Korean – 한국어 (PDF) 671kB 05/29/19

Glossary of Health Coverage and Medical Terms

• Glossary of Health Coverage and Medical Terms – English (PDF) 117kB 07/22/16
• Glossary of Health Coverage and Medical Terms – Spanish - Español (PDF) 138kB 07/22/16
• Glossary of Health Coverage and Medical Terms – Chinese Mandarin - 中文 (PDF) 447kB 07/22/16
• Glossary of Health Coverage and Medical Terms – Navajo – Diné bizaad (PDF) 230kB 07/22/16
• Glossary of Health Coverage and Medical Terms – Korean – 한국어 (PDF) 1.2MB 07/22/16

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.