Additional Health Insurance Coverage
To coordinate medical or dental benefits for members covered by another health, dental or Medicare insurance.
Complete the online form (login required)
Download the form (pdf)
Accident/Injury Questionnaire Form
To ensure a claim for an injury or illness resulting from an accident, such as a slip and fall, is processed correctly.
Complete the online form (login required)
Download the form (pdf)
Authorization to Release Information Form
To authorize Harvard Pilgrim to release/disclose certain health information according to the terms you specify.
Behavioral Health Claim Form
To claim reimbursement for covered Behavioral Health services received out-of-network.
Designation of Representative Form
To authorize an individual to discuss and make decisions related to your health care and coverage.
Fitness Reimbursement Form
To claim reimbursement for an approved health club or fitness facility membership that you have paid for out-of-pocket.
Medical Reimbursement Form
To claim reimbursement for medical and hospital services covered under your plan that you have paid for out-of-pocket.
Personal Representative Cover Form
If you are the Personal Representative (e.g., health care proxy, power of attorney, etc.) of a member, please complete and submit this form with your legal documentation in order to be documented in Harvard Pilgrim’s system.