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

2018 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

Make Changes to your address, family members, etc.

If you signed up through, please call 800-318-2596 or log in at to make changes to your plan.

If you signed up directly with Montana Health CO-OP, click here to download the change form.

2018 Appeal Form

Click here for information on your appeal rights.

Click here for an online form to file an appeal.

Claims Forms for 2017

2017 Medical Claims
Mail Medical Claim form to:
Montana Health Coop
PO Box 7147
London, KY 40742

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

2017 Member-Designated Representative Form

2017 Appeal Checklist

Mail to:
Altius Health Plans
Appeals Dept.
PO Box 7147
London, KY 40742

Use this form to help gather information that is useful when appealing

2018 Individual/Family Applications—Direct Purchase from Montana Health CO-OP with No Tax Credit