Welcome Members!

Here you will find tools and resources to help you better manage your pharmacy benefits.

Maximize Your Pharmacy Benefits

Member Resources: Forms and Documents

HIPAA & Designation of Authorized Party Forms

Appoint a Representative

This form is used to to provide the person named authority to access my Protected Health Information (PHI) to assist in my treatment and/or payment for that treatment. Select the link below to download the Designation of Authorized Party Form in your preferred language:

• Designation of Authorized Party Form
• Designation of Authorized Party Form - Spanish

Consent and Acknowledgement of Receipt of Privacy Notice

This form is used to acknowledge the use and disclosure of my personal protected health information for the purposes of treatment, payment and healthcare operations.

• HIPAA Consent and Acknowledgement of Receipt of Privacy Notice Form
• HIPAA Consent and Acknowledgement of Receipt of Privacy Notice Form - Spanish

Release Protected Health Records (Authorization or Revocation)

This form allows you to authorize - or revoke the authorization of - the release of your protected records to a named party such as a family member, health aid, doctor's office, or pharmacy.

• HIPAA Release/Revoke Form
• HIPAA Release/Revoke Form - Spanish

Reimbursement Forms

You may be able to complete your reimbursement request in your Member Portal account. To learn more, log in to your Member Portal account.

• Member Reimbursement Form
• Member Reimbursement Form Spanish
• Member Reimbursement Form for BIN 800004

Facts about Generics

• Click here to download the Facts about Generics flyer in English.
• Click here to download the Facts about Generics flyer in Spanish.

Your Rights and Responsibilities

• Member Rights and Responsibilities

Proper Medication Disposal and Handling

Download tips on proper medication disposal and handling.

• English
• Spanish