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.
You have the following option(s) for submitting claims for services received from non-network providers: using our online tool or mailing a claim.
File an out-of-network claim for behavioral health services online (requires login)
Mail completed claims forms to:
Claims Processing
P.O. Box 30760
Salt Lake City, UT 84130-0760
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.
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.
EAP Wellness Assessment (Adult) - 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 a complaint or appeal. You may also file a complaint or appeal by calling the number on the back of your 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.