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Behavioral health plan

Find the form you need for:

Claims

Network Advantage

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

Mail completed claims forms to:
 

Claims Processing
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.


Managing your health

Confidential Exchange of Information - Use this form to give permission for your behavioral health provider to contact your medical doctor. This is important 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. It is critical to your overall health that your behavioral health provider knows about any medical problems you may have. Contact with your medical doctor ensures you get the best and safest treatment.

Managing Your Healthcare Information - The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule gives you rights over your protected health information (PHI), including the right to get it, change it, share it and monitor it. The forms on the following page will help you manage your healthcare information.

Release of Information - 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 - Complete this brief pre-visit questionnaire about your emotions and feelings. Take and review it with your clinician to help get services to best meet your needs. Use this form to evaluate your child's emotions and feelings.

Grievance form - Use this form if you would like to file an EAP or Behavioral Health related complaint. If you would like to file an appeal, please call the number on the back of your insurance card.

Appointment of Representative - A Commercial member (or “patient”) may use this form to designate an authorized representative to act on his or her behalf regarding a grievance, or an appeal of a denial of service or payment.