Prescription Claim Form

A form to request reimbursement for out of pocket payment of prescription drugs

Mail Order Prescription Form

Medical Claim Form

Special Enrollment Period Validation List

A list of Special Enrollment reasons and verification documents

Member-Designated Representative Form

A form to allow MHC to release information to someone else

Monthly Premium Withdrawal Form

A form to authorize monthly payments

Change Form

A form to report changes to off exchange coverage

If you are a Marketplace, or Healthcare.gov member, please call 1.800.318.2596 to update your address or household information

Appeals

Information on your appeal rights.

Click to go to an online form to file an appeal.

Anti-Discrimination Policy

Incapacitation Review 

Direct Application - ID

Direct Application - MT

Direct Application - WY