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 information on your appeal rights.

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