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Easy-Access Member Claims Forms
Here are printable claims forms for your convenience. However, it is even easier to submit eForms through your Member account. If you have any questions, please call our Customer Service Contact Center at the number listed on your ID card or access Live Chat.
Requests for enrollment or benefit change forms are made through your company’s benefits administrator or Human Resources department.
Medical And Dental Claim Forms
If you received care or a bill from an out-of-network provider, use these forms to submit a claim for reimbursement or to request coverage.
Continuity of Care Accommodation Application
Use this form to request a continuity of care accommodation under the No Surprises Act.
Authorization to Release Information
Members can use the following forms to give MedCost permission to share information about themselves (or a dependent) with another person or organization.
Flexible Spending Account (FSA) Reimbursement
Reimbursement forms related to your flexible spending account (FSA).
Transition of Care
Request continuation of care with a non-network provider.
Adobe Acrobat Reader is required to view/print PDF files. You can download the Reader for free from www.adobe.com.
Additional forms can be found within your secure Member account (Accident Details, Coordination of Benefits and Subrogation). To access these interactive forms, you must be a registered user and be logged in.
