DOCUMENTS & FORMS

Forms you may need

We've put together the most common documents and forms you might need for things like filing claims or reviewing your coverage.

Enrollment

Use these resources to help you enroll in a plan.

PDF iconEnrollment Form

Benefits & Coverage

These documents contain information about your benefits, network and coverage.

PDF iconLow Income Subsidy (LIS) Premium Summary Chart

PDF iconSummary of Benefits

PDF iconEvidence of Coverage (EOC)

PDF iconHealth Incentives

Your Rights

You'll find notices and forms in this section that’ll help you understand your rights and responsibilities and make requests related to those rights.

PDF iconAppointment of Representative Form

PDF iconHIPPA Form

PDF iconPersonal Representative Request Form

PDF iconNotice of Privacy Practices

PDF iconRequest Confidential Communication

Grievances & Appeals

Use these forms to file an appeal about coverage or payment decisions or to file a grievance if you have concerns about your plan, providers or quality of care.

PDF iconMember Appeal Form

PDF iconMember Grievance Form

PDF iconDiscrimination Grievance Form

*Shared Health Dual Plus Star Rating: Plan too new to be measured