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Forms & Documents

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Forms available for PrimeCare members. If you have any questions regarding a form, please call Customer Service at 1-800-956-8000. All forms can be opened and downloaded in a PDF format.*

Authorization for the Use and/or Disclosure of Protected Health Information (PHI) form:

This form is used to authorize & give access to your personal health information to a family member or caregiver on your behalf.

Select one of the following links for more details and to obtain the form:

Appeal and Grievance Forms:

If you are dissatisfied with the service provided by your primary care physician, medical group or any provider affiliated with your medical group, you have the right to file a complaint or grievance with your health plan.

Select one of the following links for more details and to obtain the form:

Advance Directives:

When a member has made their wishes known in regards to end-of-life care, the patient's treating physician(s) will honor the wishes as described in the advance directives. The presence of advance directives does not influence the availability or access to physicians, medical services or covered benefits except to remain congruent with the wishes stated in the advance directives. The advance directives can be revoked at any time.

Click here for more information on Advance Directives

Health Information Exchange (HIE) Forms:

Member Reimbursement:

* Forms are available in Adobe PDF format (printer-ready.) The free Adobe Reader (for PDF format) software can be downloaded by clicking here