Medicare Supplement Plan Forms

• 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 (pdf)
  To authorize Harvard Pilgrim to release/disclose certain health information according to the terms you specify.
• Behavioral Health Claim Form (pdf)
  To claim reimbursement for covered Behavioral Health services received out-of-network.
• Designation of Representative Form (pdf)
  To authorize an individual to discuss and make decisions related to your health care and coverage.
• Fitness Reimbursement Form (pdf)
  To claim reimbursement for an approved health club or fitness facility membership that you have paid for out-of-pocket.
• Medical Reimbursement Form (pdf)
  To claim reimbursement for medical and hospital services covered under your plan that you have paid for out-of-pocket.
• Personal Representative Cover Form (pdf)
  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.