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Claims

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 – En Español (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 – En Español (Spanish) (PDF)
• Commercial GRIEVANCE FORM – Chinese (PDF)

Other Helpful Forms

• Continuity of Care Assistance Request Form – English (PDF)
• Continuity of Care Assistance Request Form – En Español (Spanish) (PDF)
• Behavioral Health Provider Nomination Form – English (PDF)
• Disabled Dependent Certification Form – English (PDF)
• Out-of-Pocket Maximum Notification – English (PDF)

HIPAA Disclosures

• Authorization For Disclosure of PHI – English (PDF)
• Authorization For Disclosure of PHI – En Español (Spanish) (PDF)
• Authorization For Disclosure of PHI – (Chinese) (PDF)
• Authorization For Disclosure of PHI – (Korean) (PDF)

Pharmacy

Mail Order Pharmacy

• CVS Caremark Mail Order Pharmacy – English (PDF)
• CVS Caremark Mail Order Pharmacy – En Español (Spanish) (PDF)

Prescription Claims

• Prescription Drug Claim Form (Commercial Members) – English (PDF)
• Prescription Drug Claim Form (Commercial Members) – En Español (Spanish) (PDF)