Forms
Advanced Directives
My Advance Care Plan (Form)
PDF, 367 KB
PDF, 367 KB
My Advance Care Planning Guide
PDF, 2 MB
PDF, 2 MB
Authorizations for Release of Medical Information
Authorization for Use or Disclosure of Medical Information (Designated Representative)
PDF, 115 KB
PDF, 115 KB
Authorization for Use or Disclosure of Medical Information - THIS FORM MUST BE USED BY HEALTH EQUITY MEMBERS ONLY
PDF, 285 KB
PDF, 285 KB
Authorization to Release/Obtain PHI
PDF, 71 KB
PDF, 71 KB
Revocation of Authorization Form
PDF, 82 KB
PDF, 82 KB
Personal Health Information (PHI) Restriction Form
PDF, 80 KB
PDF, 80 KB
Disabled Dependent Certification Form
PDF, 562 KB
PDF, 562 KB
Formulario de Certificación de Dependiente Discapacitado
PDF, 536 KB
PDF, 536 KB
BusinessEDGE
Employer Sign In
Member Appeals Forms
Members Complaints Packet
PDF, 167 KB
PDF, 167 KB
Members Complaints Packet (Family Care)
PDF, 100 KB
PDF, 100 KB
Out of Area Dependent Child Forms
Pharmacy Mail Order Forms
Mail Order Frequently Asked Questions
PDF, 431 KB
PDF, 431 KB
Mirena Eligibility Form
PDF, 71 KB
PDF, 71 KB
Mirena Order Form
PDF, 42 KB
PDF, 42 KB
Specialty Pharmacy FAQs (Proprium Pharmacy)
PDF, 152 KB
PDF, 152 KB
Pharmacy Reimbursement Form
Transitional Care
The American Recovery and Reinvestment Act of 2009 Forms
Virginia Small Employer COBRA
PDF, 70 KB
PDF, 70 KB