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

• Click here to download the medical claim form

Special Enrollment Period Validation List

• Click here to see a list of Special Enrollment reasons and verification documents

2018 Member-Designated Representative Form

• Click here for a form to allow MHC to release information to someone else

2018 Monthly Premium Withdrawal Form

• Click here for a paper form to authorize monthly payments

2018 Change Form

• Click here to download a form to report changes to off exchange coverage

2018 Appeal Form

Click here for an online form to file an appeal.

2017 Appeals

• Use this form to help gather information useful when appealing
• 2017 External Review Request Form

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 Medical Claim Form

2017 Rx Claims

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

• 2017 Rx Claim Form