Member appeal and authorization form - Request an appeal of a decision and/or give your permission for another person to submit an appeal on your behalf.
Independent Review Organization (IRO) - These are external medical and contract experts not associated with LifeWise. We’ll forward your request at no additional cost to you. Please complete the internal appeal process with LifeWise prior to submitting an IRO request
Member complaint form - Send a complaint if you’re feeling unhappy and only wanting to share your opinion with LifeWise.
Complaint and appeal rights - Learn about your appeal rights.
Dependent care account claim form
FSA/HRA expense manual claim form
HSA expense manual claim form
Authorization for appeals - Provide your approval for another party to submit an appeal on your benefit.
Authorization for release of psychotherapy notes - Complete this form to allow access to notes made by medical professionals providing psychiatric
or psychological services.
Disclosure accounting request - Request a record of how we disclose information about you for reasons other than our normal business functions.
Information release form - Give someone permission to obtain and discuss your personal and health information, including sensitive information such as substance abuse, reproductive health, and mental health. You can also authorize members on your plan to see your sensitive information on LifeWiseOR.com or ConnectYourCare (medical funding account).
Member appeal form - Request an appeal of a decision.
Member appeal process - Learn about your appeal rights.
Request for amendment of records - Change your official personal information we maintain using this form.
Non-disclosure request - Ask us not to share information with someone that you name because it could affect your safety.
Request for inspection of records - Request certain records that we maintain containing your personal information.
UMB HSA account application - An application to help set up an HSA bank account at UMB Bank
Authorization for collection, use and disclosure of personal information for underwriting and enrollment
Grandfathered and extended plans dental copay listing
Grandfathered and extended plans dental sales brochure
Coordination of benefits questionnaire
Deductible credit form
Request for certification of disabled dependent
Student status verification
Health, allergy & medication questionnaire - Complete this questionnaire for all new mail prescriptions to help protect yourself against potentially harmful drug interactions and side effects.
Express Scripts home delivery mail-order form - Request home delivery of your medications.
Prescription drug reimbursement form - Apply for reimbursement of your prescription costs.
Secondary coverage claim form - Request reimbursement for the balance of your prescription costs.