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Enrollment Forms

• Health Plan/Health Network Application and Change Form

Claim Forms

• Out-of-Network Care Claim Form
• Pharmacy Program Direct Reimbursement Claim Form
• Coordination of Benefits Verification
• Health Reimbursement Arrangement (HRA) Claim Form

Provider Network Forms

• Member Health Survey and Transition of Care Application
• Provider Nomination Form

Employer Group Termination Forms

• Membership Termination Form

Employer OnLine Forms

• Employer OnLine User Application

HIPAA Privacy Forms

• Notice of Privacy Practices
• Personal Representative Designation Form
• Member Authorization to Use/Disclose PHI

Other Helpful Information

• Member Handbook
• Complaint & Grievance Process for UPMC Health Plan Members
• UPMC Health Plan Member Rights & Responsibilities
• Pre-Authorization Quick Reference Guide