Forms
Get a form to file a claim, get authorization, appeal a decision and more.
- Declaration of domestic partnership
- Individual adult dental copay plan – Add adult dental coverage to an individual metallic plan.
- UMB HSA account application – Set up an HSA bank account at UMB Bank.
- Tobacco certification form – For plans as of 1/1/14 enrollment dates.
- Department of Retirement Service (DRS) – Retired city employees on individual and family plans or Medicare plans can deduct their premium tax-free from their pension income.
- Application for the addition of family members – Add family members to an existing grandfathered plan.
- Claim form
- HSA expense manual claim form – Reimbursement for qualified out-of-pocket medical expenses if your client has a health savings account (HSA).
- Incident questionnaire – If your client has sustained an injury or was involved in an accident.
- Dependent care account claim form
- Other coverage questionnaire
- Discount card reimbursement – Reimbursement for prescription costs if your client is a member of the Affordable Care Act's Drug Discount Program.
- Prescription drug reimbursement – Reimbursement for prescription costs.
- Express Scripts mail-order form – Request home delivery of medications.
- Health, allergy & medication questionnaire – Questionnaire for all new mail prescriptions to help protect against potentially harmful drug interactions and side effects.
- Secondary coverage claim form – Reimbursement for the balance of prescription costs.
- Authorization for release of psychotherapy notes – Allows access to notes made by medical professionals providing psychiatric or psychological services.
- Disclosure accounting request – Request a record of how we disclose information about your client for reasons other than our normal business functions.
- Information release form – Give permission to obtain and discuss your personal and health information, including sensitive information such as substance abuse, reproductive health, and mental health. Your client can also authorize members on your plan to see your sensitive information on lifewise.com or ConnectYourCare (personal funding account).
- Non-disclosure request form – Requests concerning sharing health information.
- Request for amendment of records – Change official personal information we maintain using this form.
- Request for inspection of records – Request certain records that we maintain containing your client’s personal information.
- Member appeal and authorization form – Request an appeal of a decision and/or give permission for another person to submit an appeal on your client’s behalf.
- Independent Review Organization (IRO) – These are external medical and contract experts not associated with LifeWise. We’ll forward your request at no additional cost to you. Please complete the internal appeal process with LifeWise prior to submitting an IRO request
- Member complaint form – Send a complaint if you’re feeling unhappy and only wanting to share your opinion with LifeWise.
- Complaint and appeal rights – Learn about your appeal rights.