Health Plan Forms

Download and print the health plan form you need.

• Applied Behavioral Analysis (ABA) Authorization Form (PDF)
• Authorization for the Release of Protected Health Information (PDF)
• AZ Prior Authorization Request Form (PDF)
• Behavioral Health Injectable Antipsychotic Prior Authorization Form (Genoa Pharmacy) (DOC)
• Coordination of Benefits Form (PDF)
• Employee Enrollment and Change Form (PDF)
• Employee Enrollment and Change Form - Spanish (PDF)
• 2023 Individual Off Exchange Application Form (PDF)
• 2023 Individual Off Exchange Application Form – Spanish (PDF)
• 2023 Individual Off Exchange Member Change Form (PDF)
• 2023 Individual Off Exchange Member Change Form – Spanish (PDF)
• 2024 Individual Off Exchange Application Form (PDF)  
• 2024 Individual Off Exchange Member Change Form (PDF)
• Medical Necessity Request Form (PDF)
• Nevada Claim Form (PDF)
• New Prescription Fax Order Form (PDF)
• Primary Care Physician Change Request Form (PDF)
• Pharmacy Reimbursement Claim Form (PDF)
• QOC Internal Referral Form (PDF)
• Substance Abuse Records Release Form (PDF)
• Transition of Care and Continuity of Care Form (PDF)

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.