Member materials and forms

Member materials 

Integrative health services member handbook ― English (PDF) | Spanish (PDF)

Mental health and substance use treatment services handbook ― English (PDF) | Spanish (PDF)

Provider and pharmacy directory (PDF)

Clinical Practice Guidelines (PDF)

Forms

Submit a Grievance (PDF)

Member Appeal Form (PDF)

Authorization to release protected health information (PHI) (PDF)

Authorization to release psychotherapy notes (PDF)

Fraud, waste and abuse form

Grievance and appeal form

Member advisory committee application ― English (PDF) | Spanish (PDF)

Notification of pregnancy (PDF)

Transition of care form ― English (PDF) | Spanish (PDF)

Notice of Privacy Practices  ― English (PDF) | Spanish (PDF)

Protected health information (PHI) access request form GR-69238-1 — English | Spanish

Request for an Accounting of Disclosures of Protected Health Information (PHI) GR-69239-1 — English | Spanish

Protected health information (PHI) release form GR-69126-1 — English | Spanish

Authorization to release psychotherapy notes GR-69127-1 — English | Spanish

Removal of Authorization Previously Given to Aetna GR-69240-1 — English | Spanish

2024 Value Added Benefits (PDF)

Q3 EAC Meeting Minutes (PDF)