Documents & Forms Center

Agents, Employers, Members

Non-Medicare Prescription Drug Reimbursement Request

PDF icon Non-Medicare Prescription Drug Reimbursement Request _ 2022 Updated.pdf

Notice of Privacy Practices

PDF icon Notice of Privacy Practices 5-21-2020.pdf

Members

Parental Consent for Care of Minor Children

PDF icon Parental-Consent-for-Minor-Children_CHP-41.pdf

Providers

Patient Headache Diary

PDF icon MMS-HEADACHE-DIARY-0424.pdf

Members

Patient Health Questionnaire

PDF icon Patient Health Questionnaire (PHQ-9).pdf

Providers

Pediatric Health Assessment

PDF icon Pediatric Health Assessment.pdf

Providers

Pediatric Health Assessment 2022

PDF icon Pediatric-Health-Assessment-2022-FINAL.pdf

Providers

Perinatal Care

PDF icon Perinatal Care.pdf

Perinatal Care 2022

PDF icon Perinatal-Care-QIC-03-2022-FINAL.pdf

Medicare

Personal Medication List

PDF icon Personal Medication List.pdf

Agents, Employers, Members

Pregnancy And Coverage FAQ

PDF icon Pregnancy And Coverage FAQ.pdf

Premier PLUS Selection 15.30.50 1-1-22

PDF icon Premier PLUS Selection 15.30.50 1-1-22.pdf

Premier PLUS Selection 15.30.50 10-01-21

PDF icon premier-plus-selection-15.30.50-10-01-21.pdf

Agents, Employers

Premier PLUS Selection 15.30.50 10-1-19

PDF icon Premier PLUS Selection 15.30.50 10.01.19.pdf

Agents, Employers

Premier PLUS Selection 15.30.50 10-1-19 20%

PDF icon Premier PLUS Selection 15.30.50.20 10.01.19.pdf

Premier PLUS Selection 15.30.50 20% 1-1-23

PDF icon Premier-PLUS-Selection-15.30.50-20percent-1-1-23.pdf

Premier PLUS Selection 15.30.50 20% 1-1-22

PDF icon Premier PLUS Selection 15.30.50 20% 1-1-22.pdf

Premier Selection 15.30.50 1-1-22

PDF icon Premier Selection 15.30.50 1-1-22.pdf

Premier Selection 15.30.50 1-1-23

PDF icon Premier-Selection-15.30.50-1-1-23.pdf

Premier Selection 15.30.50 10-01-21

PDF icon premier-selection-15.30.50-10-01-21.pdf

Agents, Employers

Premier Selection 15.30.50 10-1-19

PDF icon Premier Selection 15.30.50 10.01.19.pdf

Agents, Employers

Premier Selection 15.30.50 10-1-19 20%

PDF icon Premier Selection 15.30.50.20 10.01.19.pdf

Premier Selection 15.30.50 20% 1-1-22

PDF icon Premier Selection 15.30.50 20% 1-1-22.pdf

Premier Selection 15.30.50 20% 1-1-23

PDF icon Premier-Selection-15.30.50-20percent-1-1-23.pdf