
MEMBER FORMS
Member Forms
Click to access or download each.
Add-On Family Form
Add-on a new family member.
BMI Verification
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.
Measurements for height, and weight taken within the last 30 days are acceptable.
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