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For Members

Forms for Members

Use the links below to print/view copies of our most frequently used forms.

  • Health-Related 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
  • Claim Forms

  • 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
  • Dental Coverage Attestation Form
  • Dependent Certification Form
  • Disabled Dependent Form
  • Classic Univera Traditional, Classic Univera Comprehensive, Univera PPO, Signature Series, & Dental
  • ActiveUnivera
  • Member Change Form for Direct Purchase Plans
  • valUcare
  • Young Adult Option Certification Form
  • Prior Coverage Verification Form