Helpful Forms


Claims

Generally, claims will be submitted by your network provider. However, if you use a non-network provider, you will need to submit the claim.

To mail your claim, Download and print the CMS-1500 Claim Form PDF using Adobe Acrobat Reader. To make sure your claim gets processed correctly the first time, click here to download a tip sheet on how to submit a claim.

Mail completed claims forms to:

   P.O. Box 30755
   Salt Lake City, UT  84130-0755

Note regarding medical claims: If you have questions or concerns regarding a medical claim, please refer to the phone number on your insurance card.



Confidential Exchange of Information

Download the "Confidential Exchange of Information Form" PDF using Adobe Acrobat Reader. We suggest that your behavioral health clinician contact your medical doctor because:

  • You may be getting medicines from both your behavioral health clinician and your medical doctor. Sometimes medicines don't work well if mixed together. Your doctors need to know about other medicines that you are taking.
  • Your behavioral health clinician needs to know about any medical problems.
  • Contact with your medical doctor ensures you get the best and safest treatment.

For complete instructions and to read more about how this exchange of information benefits you, download this tip sheet. PDF.



Release of Information Form

Click here to complete the "Release of Information Form."exticon Member must complete the release of information form, include all necessary documentation and electronically sign before information will be sent to a third party (i.e. physician’s office or insurance company) or discussed with an individual that you designate.



Wellness Assessment Form

Download the "Wellness Assessment Adult Form"PDF or the "Wellness Assessment Youth Form"PDF using Adobe Acrobat Reader.

Complete this brief pre-visit questionnaire about you or your child’s emotions and feeling. Take and review it with your clinician to help get services to best meet your needs.








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