Member Forms and Brochures

Instructions to complete the reimbursement form for Over-the-Counter (OTC) COVID-19 tests

• Medical Claim Form for Group and Individual & Family Plans – English (PDF)
• Medical Claim Form for Group and Individual & Family Plans – En Español (Spanish) (PDF)

Important: Complete a separate form for each member asking for reimbursement for covered services and for each doctor and/or facility. To avoid processing delays, please include the following information with this form:

• Copy of itemized bill showing all services received. Must include name, address, phone number, tax ID number of doctor and/or facility, date of service and all diagnosis and procedure codes.
• Proof of payment for reimbursement requests over $200. "Proof of Payment" includes: a copy of the credit card charge slip or online statement, canceled checks, a bank account statement, cash withdrawal slips, or a cruise ship statement. Note: Invoices are not acceptable proof of payment.
• See the instructions in Section 4 for Foreign Claim Questionnaire for services received outside of the U.S

Other Forms

• Medicare - Medical and Behavioral Health Claim Form – English (PDF)
• Medical and Behavioral Health Claim Form – English (PDF)
• IFP and Group Member Grievance Form – English (PDF)
• IFP and Group Member Grievance Form – Chinese (PDF)
• IFP and Group Member Grievance Form – En Español (Spanish) (PDF)
• Appointment of Representative Form CMS-1696

Please explain in detail the circumstances that led to your dissatisfaction with Health Net. Please include the original copy of any claims or bills received which are related to your issue.

• Dental Claim Form – English (PDF)
• Medicare Supplement Plan Claims
• Out-of-Network Vision Claim Form (non-Medicare) – English (PDF)

• Foreign Claims Questionnaire – English (PDF)
• Foreign Claims Questionnaire – En Español (Spanish) (PDF)

For Healthy Families, Healthy Kids and AIM plan members. Medi-Cal members please contact Member Services.

Pre-enrollment Material

• Welcome Letter – English (PDF)
• Gracias por su Interés en Health Net – En Español (Spanish) (PDF)
• Choice Form Flyer – English (PDF)
• Cómo Inscribirse en un Plan Medi‑Cal de Health Net – En Español (Spanish) (PDF)

New Member Welcome Booklets

Is there a Cigna Provider Nomination process/form?
No, there is no form. Members can contact Health Net Member Services at the number on their Member ID card to request that a provider be added to the Cigna Healthcare PPO Network.

• Preventive Care Services (ACA Non-Grandfathered Plans) – English (PDF)
• Preventive Care Services (ACA Non-Grandfathered Plans) – En Español (Spanish) (PDF)
• Continuity of Care Assistance Request Form – English (PDF)
• Continuity of Care Assistance Request Form – En Español (Spanish) (PDF)
• Disabled Dependent Certification Form – English (PDF)
• Timely Access Member Flyer – English (PDF)
• Timely Access Member Flyer – En Español (Spanish) (PDF)
• Home Infusion Fact Sheet – English (PDF)

To request special, confidential handling of your medical information, also called protected health information (PHI), please visit Confidential Communication Request. Forms in additional languages are also available.

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 (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)

Home Infusion Fact Sheet – English (PDF)

Medicare Advantage - Employer Group Plan Materials

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

• Authorization For Use or Disclosure of Medical Information – English (PDF)
• Authorization For Use or Disclosure of Medical Information – En Español (Spanish) (PDF)
• Authorization For Use or Disclosure of Medical Information – Arabic (PDF)
• Authorization For Use or Disclosure of Medical Information – Armenian (PDF)
• Authorization For Use or Disclosure of Medical Information – Cambodian (PDF)
• Authorization For Use or Disclosure of Medical Information – Chinese (PDF)
• Authorization For Use or Disclosure of Medical Information – Farsi (PDF)
• Authorization For Use or Disclosure of Medical Information – Hmong (PDF)
• Authorization For Use or Disclosure of Medical Information – Korean (PDF)
• Authorization For Use or Disclosure of Medical Information – Russian (PDF)
• Authorization For Use or Disclosure of Medical Information – Tagalog (PDF)
• Authorization For Use or Disclosure of Medical Information – Vietnamese (PDF)

HIPAA authorization forms required for requesting applicant and member medical records.

• Medi-Cal - GRIEVANCE FORM
• Medi-Cal Dental - GRIEVANCE FORM

• Continuity of Care – English (PDF)
• Continuity of Care – Arabic (PDF)
• Continuity of Care – Armenian (PDF)
• Continuity of Care – Cambodian (PDF)
• Continuity of Care – Chinese (PDF)
• Continuity of Care – Hmong (PDF)
• Continuity of Care – Farsi (PDF)
• Continuity of Care – Korean (PDF)
• Continuity of Care – Russian (PDF)
• Continuity of Care – En Español (Spanish) (PDF)
• Medi-Cal Continuity of Care – En Español (Spanish) (PDF)
• Continuity of Care – Tagalog (PDF)
• Continuity of Care – Vietnamese (PDF)

• 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 (PDF)
• Glossary of Health Coverage and Medical Terms - Navajo (PDF)
• Glossary of Health Coverage and Medical Terms - Korean (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.