Forms | Mountain Health COOP

Covering Idaho, Montana, and Wyoming

Plan Administrator - University of Utah Health Plans

Member Forms

Click on buttons below to download the forms you need.

Prescription Claim Form

Prescription Claim Form

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

Mail Order Prescription Form

Mail Order Prescripton

Medical Claim Form

Medical Claim Form

Special Enrollment Period Validation List

A list of Special Enrollment reasons and verification documents

Member-Designated Representative Form

Information Release

A form to allow Mountain Health CO-OP 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

Change Form - WY

For group changes, please talk to your HR department.

Appeals

Appellant Rights

Information on your appeal rights.

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

External Review Request Form - WY

Anti-Discrimination Policy

Anti-Discrimination Policy

Incapacitation Review

Incapacitation Review

Direct Application - ID

Direct Application

Direct Application - MT

Direct Application

Direct Application - WY

Direct Application

Direct application only, NOT marketplace applications

Preauthorization

For Prior Authorization Forms - Click Here