Necessary Forms

At times, managing your health and your finances requires the sharing of information with some of our partners. Take note of the following forms for your convenience.

2023 Medicare Part D Instructions and Reimbursement Claim Form
International Claim Form
HIPAA Authorization to Release Information
UCR Form
Manual Accident Form
Out-of-Network Claim Form (Active and Pre-Medicare Retiree only)
Medicare Claim Form
Domestic Partner Enrollment Materials
OTR Form (Mental Health)
OTR Letter
Disabled Dependent Form
COB Instructions and Form

Notice of Privacy Practices

Necessary Forms

SWSCHP • State-Wide Schools Cooperative Health Plan