Commonly Used Forms for
Commercial Members

Don’t see the form you're looking for? Call 1-888-876-2756. We are happy to help you.

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 2008 Additional Information section of our website.

Enrollment Forms

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

• 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
  
• Complaints & Grievances Process
• Member Rights & Responsibilities
  
• Pre-Authorization Quick Reference Guide