Member Forms

Click on the links below to download the forms you need.

2018 Prescription Claim Form

  • Click here for a form to request reimbursement for out of pocket payment of prescription drugs

2018 Mail Order Prescription Form

  • Click here to download the mail order prescription form

2018 Medical Claim Form

Special Enrollment Period Validation List

2018 Member-Designated Representative Form

2018 Monthly Premium Withdrawal Form

2018 Change Form

2018 Appeal Form

Click here for information on your appeal rights.

Click here for an online form to file an appeal.

2017 Appeals

Mail ONLY 2017 appeals to:
Altius Health Plans
Appeals Dept.
PO Box 7147

London, KY 40742

Fax #: 801-323-6050

 

2017 Claims Forms

2017 Mail Medical Claim form to:
Mountain Health Coop
PO BOX 7147
London, KY 40742

2017 Rx Claims

Mail 2017 Rx Claim form to:
Express Scripts
P.O. Box 14236
Lexington, KY 40512