State Member Forms

MCHCP Forms

HIPAA

Authorization to Release Protected Health Information Member Record Amendment/Correction Request for Restriction on Use and Disclosure of Health Care Information and/or Confidential Communication

State Members

Automatic Withdrawal Enroll/Change/Cancel Foster Parent Enrollment Health Savings Account (HSA) Acceptance/ Change Form Leave of Absence Enrollment Non-Contraception Benefit Option Notice of Special Enrollment Rights Quit Tobacco Promise Retiree Enrollment Survivor Enrollment Terminated Vested Enrollment Tobacco-Free Promise

Highway Patrol, MoDOT & Conservation Members (Dental & Vision Only)

Enroll/Change/Cancel Leave of Absence Enrollment Notice of Special Enrollment Rights Retiree Enrollment Survivor Enrollment Terminated Vested Enrollment

State Human Resources/Personnel Representative eMCHCP Access

EMCHCP Access Request

Health Plan Forms

Medical

Anthem International Claim Form Anthem Medical Claim Form Continuity of Care - Transition of Care Request Form

Prescription Drug Plan Forms

Express Scripts Medicare Claim Form Express Scripts Non-Medicare Claim Form

Dental & Vision

Delta Dental Claim Form NVA Claim Form