This section provides appeal information
Authorization for Appeals - Use this form to provide your approval for another party to submit an appeal on your benefit.
Member Appeal Form - Use this form to request an appeal of a decision
Complaint and Appeal Rights - Learn about your appeal rights
This section provides forms used for medical, dental claims
Dependent Care Account Claim Form
FSA/HRA Expense Manual Claim Form
HSA Expense Manual Claim Form
This section provides release of information forms
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 - Use this form to 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 - Use this form to 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 - Use this form to ask us not to share information with someone that you name because it could affect your safety.
Request for Inspection of Records - Use this form to 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 - Want your prescription drugs delivered directly to you at home? Use this form.
Prescription Drug Reimbursement Form - Apply for reimbursement of your prescription costs
Secondary Coverage Claim Form - Are you covered by more than one health plan, with LifeWise as your secondary coverage? If so, you can request reimbursement for the balance of your prescription costs.