Member Handbooks and Forms

Manuals

Here are links to the manuals and forms available to you.

• Member Handbook - English (PDF)
• Member Handbook - Spanish (PDF)
• Member Handbook - Chinese (PDF)
• Member Handbook - Haitian Creole (PDF)
• Provider Directory
• Drug Formulary List (PDF)
• Drug Formulary List (machine readable)
• Pharmacy Over the Counter Brochure (PDF)

Forms

• Request for Amendment of Health Information Form (PDF)
• Notification of Pregnancy (NOP) Form (PDF)
• Member Grievance Form (PDF)
• Member Appeal Form (PDF)
• Authorization to Use and Disclose Health Information (PDF)
  
• Revocation of Authorization to Use and/or Disclose Health Information (PDF)
  
• Request for Accessing/Inspecting/Copying Health Information (PDF)
  
• Request for Restrictions on Use and Disclosure of Health Information (PDF)
  
• Request for Accounting of Disclosures of Health Information (PDF)
  

Guides

• Benefits Booklet (PDF)

Any documents and items offered in electronic format can be requested in paper format. To request a document in paper format, please contact Member Services at 1-877-236-1341 (TTY: 711).

Once you have completed your request, the paper format item(s) will be mailed to you.