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

Appeals

Information on your appeal rights.

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

Anti-Discrimination Policy

Medical Services Electronic Form

Medication

MRI services

Synagis

Formulary Exception

Behavioral Health/Substance Treatment

Skilled Nursing Facility & Acute Rehab

Hospice Care

Home Health Care Services

Consent Allowing You to Appeal on Behalf of your Patient

Appeal Form

Prior Authorization Request Form