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Forms

File for hassle-free claim reimbursement online

Use our online form to request reimbursement for covered medications purchased at retail cost. Filing online is quick, easy, and results in faster response than filing by mail.

File a form online

If you would prefer not to file online, download your claim form as a PDF

Medicare and Medicaid forms

Arkansas prior authorization or exception request

HIPAA and your rights

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule gives you rights over your protected health information (PHI), including the right to obtain, change, share and monitor the information. These rights are collectively known as “Individual Rights.”

Learn more about HIPAA and your rights

How to exercise your rights under HIPAA

Privacy and confidentiality

Authorizing release of your health information

By submitting an Authorization for Release of Information (ROI) form, you can permit someone else to access your protected health information (PHI) or to speak about your medical care on your behalf.

Personal Representative information

By submitting a Personal Representative form, you can legally appoint or designate someone to act on your behalf.