Find the form you need for:
Requesting support and services
Request a search for childcare options - Let us look for anything from all day childcare to after-school programs.
Request a search for eldercare options - Whether they need a little help or full-time care, let us assist in finding care for the elder in your life.
Request a search for convenience service options - We can help you find resources for anything from hobbies, recreation, home repair, travel, and more.
Request a search for parenting support groups, classes and more - Prenatal classes, postpartum support, parenting classes for any parent and parenting situation.
Request a search for educational opportunities - We can help find education resources for pre-school through high school and beyond (college, certification programs, distance learning, etc.).
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.