Forms and Documents

This page includes important forms and documents to help you get the most out of your First Choice Next plan for now and whatever is next.

Do you have a question or need help with a form? Call Member Services at 1-833-983-7272 (TTY 711).

Claim forms

• Member Reimbursement Medical Claim Form (PDF)

Important Plan Documents

• Evidence of Coverage (PDF)
• Member Handbook (PDF)
• Member Welcome Brochure (PDF)

Legal and Privacy Forms

• Authorization for Disclosure of Health Information (PDF)
• Health Care Privacy Complaint Form (PDF)

PHI Forms

• Personal Representative Request Form (PDF)
• Request for Access and/or Inspect Protected Health Information in a Designated Record Set (PDF)
• Request for Alternate Means of Confidential Communications (PDF)
• Request to Amend Protected Health Information (PDF)
• Request for List of Disclosures of Protected Health Information (PDF)
• Request to Restrict the Use and/or Disclosure of Protected Health Information (PDF)
• Revocation of Alternate Means of Confidential Communications (PDF)