Member Forms

Click on buttons below to download the forms you need.

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

Member-Designated Representative Form

Monthly Premium Withdrawal Form

Change Form

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 only, NOT marketplace applications

Preauthorization

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Mountain Health CO-OP does not discriminate based on race, color, national origin, disability, age, sex, gender, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.

 

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