Use the links below to print/view copies of our most frequently used forms.
Advance Care Planning
- for health care proxies, living wills and more
Manage Your Privacy
Prescription Claim Forms
Prescription Drug Claim Form 2017
- Use for prescriptions that were purchased on or after Jan. 1, 2017.
Prescription Drug Claim Form 2016
- - Use for prescriptions that were purchased during the year 2016.
Compound Prescription Drug Claim Form 2016
- Use for prescriptions that were purchased during the year 2016. The Compound Prescription Drug Claim Form must also accompany the Prescription Drug Claim Form (enclosed) for all compound medications
Dental Claim Form
Medical Claim Form
valucare Gym Membership Incentive Reimbursement Form
Surprise Bill Assignment of Benefits Form
- Use this form if you receive a surprise bill for health care services.
$300 Univera Fit Dollars Reimbursement Form
Membership & Enrollment Forms
Special Enrollment Attestation
Univera POS Select
Continuing Coverage for Students on Medical Leave Form