Forms

Medical and Behavioral Health Claim Form

• Health Net Claim Form – English (PDF)
• Health Net Claim Form – En Español (Spanish) (PDF)

Medicare - Medical and Behavioral Health Claim Form

• Health Net Medicare Claim Form – English (PDF)

Group Member GRIEVANCE FORM

• Commercial GRIEVANCE FORM – English (PDF)
• Commercial GRIEVANCE FORM – En Español (Spanish) (PDF)
• Commercial GRIEVANCE FORM – Chinese (PDF)

Medicare Supplement Plan Claim Form

• Medicare Supplement Plan Claim Form

Department of Managed Health Care (DMHC)

• Right to Submit Request for Review of Cancellation, Rescission, or Nonrenewal of Your Plan Contract, Enrollment, or Subscription – English (PDF)
• Request for Review of Cancellation, Rescission, or Nonrenewal of Plan Contract – English (PDF)

Continuity of Care Assistance Request Form

• Continuity of Care Assistance Request Form – English (PDF)
• Continuity of Care Assistance Request Form – En Español (Spanish) (PDF)

Disabled Dependent Certification Form

• Disabled Dependent Certification Form – English (PDF)

Mail Order Pharmacy

• CVS Caremark Mail Order Pharmacy – English (PDF)
• CVS Caremark Mail Order Pharmacy – En Español (Spanish) (PDF)

Prescription Claims

• Prescription Drug Claim Form (Medicare Members) – English (PDF)
• Prescription Drug Claim Form (Commercial Members) – English (PDF)
• Prescription Drug Claim Form (Commercial Members) – En Español (Spanish) (PDF)

Prescription Transition Form

• Prescription Transition Form (Commercial Members) – English (PDF)
• Prescription Transition Form (Commercial Members) – En Español (Spanish) (PDF)

Authorization For Disclosure of PHI

• Authorization For Disclosure of PHI – English (PDF)
• Authorization For Disclosure of PHI – En Español (Spanish) (PDF)
• Authorization For Disclosure of PHI – Chinese Mandarin 中文 (PDF)
• Authorization For Disclosure of PHI – Korean 한국어 (PDF)

Glossary of Health Coverage and Medical Terms

• Glossary of Health Coverage and Medical Terms – English (PDF)
• Glossary of Health Coverage and Medical Terms – En Español (Spanish) (PDF)
• Glossary of Health Coverage and Medical Terms – Chinese Mandarin 中文 (PDF)
• Glossary of Health Coverage and Medical Terms – Navajo – Diné bizaad (PDF)
• Glossary of Health Coverage and Medical Terms – Korean 한국어 (PDF)

Health insurance companies and group health plans are required to make available a uniform glossary of health coverage and medical terms commonly used in plan documents. The Uniform Glossary is meant to help the consumer understand some of the most common language used in health insurance documents. Please log in to request a hardcopy of the document by mail.