Medical Claim Form for Commercial members
Complete the claim form for each member submitting bills for reimbursement of covered services. To avoid any delay, be sure to answer each question completely. PLEASE ATTACH FULLY ITEMIZED BILLS AND PROOF OF PAYMENT.
- Medical Claim Form for Commercial members – English (PDF)
- Medical Claim Form for Commercial members – Spanish (PDF)
Commercial Grievance Form
Please explain in detail the circumstances that led to your dissatisfaction with Health Net. Please include the original copy of any claims or bills received which are related to your issue.
- Commercial Grievance Form – English (PDF)
- Commercial Grievance Form – Chinese (PDF)
- Commercial Grievance Form – Spanish (PDF)
Other Helpful Forms
Mail Order Pharmacy
Health Net Customer Support