Health Plan Forms

• Authorization for the Release of Protected Health Information
• Employee Enrollment and Change Form
• Coordination of Benefits Form
• Applied Behavioral Analysis (ABA) Authorization Form
• Off Exchange Individual Application
• Individual Member Change Form
• Nevada Claim Form
• Primary Care Physician Change Request Form
• Pharmacy Reimbursement Claim Form 
• Substance Abuse Records Release Form
• New Prescription Fax Order Form
• Medical Necessity Request Form

If you don't see the form you're looking for, please call the Member Services number on the back of your health plan ID card.