MEMBER FORMS

Add-On Family Form Add-on a new family member. BMI Verification

Measurements for height, and weight taken within the last 30 days are acceptable.

Extra Impact Application Special assistance for Impact members in need. Medical expense form Submit medical expenses for processing. Medical expense form - out of country Submit medical expenses for processing that were incurred outside the United States. PRA Change Request Requests may be made annually within 30 days of membership date. Provider Outreach Request * Available only after an appointment is scheduled. Request member Card Submit a request for a new member card.