All forms on this page are for UPMC Health Plan members or prospective members. If you are looking for UPMC for Life forms, please visit the UPMC for Life Additional Information section of our website.

Flu Shot Reimbursement Form

• Flu Shot Reimbursement Form

Enrollment forms

• UPMC Health Plan / UPMC Health Network Enrollment Form
• Student Verification Form

Claim forms

• Out-of-Network Care Claim Form
• Flu Shot Reimbursement Form
• Pharmacy Program Direct Reimbursement Claim Form
  Note: This form is for prescription reimbursements only. Use the link above for flu shot reimbursement
• Coordination of Benefits Verification
• Health Reimbursement Arrangement (HRA) Claim Form

Provider Network forms

• Transition of Care Brochure
• Provider Nomination Form

HIPAA Privacy forms

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

Other helpful information

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