MEMBER FORMS
Member Forms
Click to access or download each.
Add-On Family Form
Add-on a new family member.
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BMI Verification
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Extra Impact Application
Special assistance for Impact members in need.
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Medical expense form
Submit medical expenses for processing.
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Medical expense form - out of country
Submit medical expenses for processing that were incurred outside the United States.
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PRA Change Request
Requests may be made annually within 30 days of membership date.
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Measurements for height, and weight taken within the last 30 days are acceptable.
pre-ELIGIBILITY
Provider Outreach Request
Providers, please request a pre-eligibility review by either calling (855) 378-6777 or completing the online form.
Pre-eligibility submission is only for the following:
- Cancer Treatment
- Elective Cardiac Procedures
- Non-emergency inpatient/outpatient surgery
- Organ/Tissue Transplant Services
- Maternity
- Imaging: MRIs and Nuclear Imaging (excluding CT Scans and xrays)
**Please be advised that pre-eligibility is required only for non-emergent procedures/medical expenses. If member requires emergent services, please proceed without submitting a pre-eligibility request and eligibility will be determined post-procedure
- Available only after an appointment is scheduled.
- This form is for Provider Visits only.
- Not applicable for Senior Program
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