- भाषा से जुड़ी सहायता चाहिए?
- ត្រូវការជំនួយភាសាឬ?
- ຕ້ອງການການຊ່ວຍເຫຼືອດ້ານພາສາບໍ່?
- Нужна помощь с языком?
- 언어 지원 서비스가 필요하신가요?
- Precisa de assistência linguística?
- Χρειάζεστε βοήθεια με τη γλώσσα;
- Need language assistance?
- Occorre assistenza con la lingua?
- Besoin d’assistance linguistique ?
- Ou bezwen asistans lengwistik?
- 需要語言協助？
- ભાષા સહાયતાની જરૂર છે?
- ¿Necesita asistencia en otros idiomas?
- هل تحتاج إلى مساعدة لغوية؟
- Bạn có cần trợ giúp về ngôn ngữ không?
- Potrzebujesz pomocy językowej?
Forms library
Access all the forms you need to help guide you on your health care journey with us.
Authorization forms
To release or disclose information among designated individuals
You’ll want to fill out the Member authorization to release PHI form (pdf). This form allows you to authorize Harvard Pilgrim to release/disclose certain protected health information (PHI), according to the terms you specify.
You’ll want to fill out the Confidential Exchange of Information form (pdf). This form allows behavioral health practitioners involved in your care to release health information to other health providers, according to the terms you specify.
You’ll want to fill out the Designation of Representative form. This form allows you to authorize an individual to discuss and make decisions related to your health care and coverage.
You may need assistance from your provider to complete this form.
In order to verify your dependent’s eligibility as a disabled adult — which includes authorization to obtain protected health information— you’ll need to fill out the Disabled Adult Dependent Verification form (pdf).
You may need assistance from your provider to complete this form.
To allow Harvard Pilgrim representatives to speak to a parent about the health coverage and care of their dependent (under age 18) when parent is not listed on that minor’s policy, a Statement of Parental Rights form (pdf) will need to be completed.
If you are the Personal Representative (e.g., health care proxy, power of attorney, etc.) of a member, please complete and submit the Personal Representative Cover Form with your legal documentation in order to be documented in Harvard Pilgrim’s system
Medicare plan forms
Forms for Medicare Advantage and Medicare Supplement Plan members
Access all the Medicare Advantage Stride forms you need — enrollment, reimbursement, prescription drug, billing, representative designation, privacy and more.
Access all the Medicare Supplement Plan forms you need — additional health insurance coverage, accident/injury questionnaire, authorizations, reimbursement, claim, representative designation and more.
Reimbursement program forms
For members whose plans include reimbursement for activities that support healthy lifestyles
Claims forms
Request reimbursement for covered plan expenses
Please fill out the Health Care Reimbursement Claim Form to request reimbursement for out-of-pocket costs that you paid for covered medical, hospital and behavioral health services. Use the Prescription Drug Reimbursement Claim form (pdf) to request reimbursement for out-of-pocket costs that you paid for covered prescription medications.
You may need assistance from your provider to complete this form.
For HMO, POS and PPO plans, to claim reimbursement for prescription medications covered under your plan that you have paid for out of pocket, you’ll want to complete the Prescription Drug Reimbursement Claim form (pdf).
To claim reimbursement for travel expenses that are primarilly for and essential to covered services that are restricted or prohibited in your state of residence as a result of state law, you’ll want to fill out the Travel Benefit Reimbursement form.
You may be eligible to claim reimbursement for a COVID-19 at-home test that you have paid for out of pocket, check eligibility and find instructions on our COVID-19 testing and coverage page.
Please fill out the Health Care Reimbursement Claim Form to request reimbursement for covered medical, hospital and behavioral health services you received from outside your plan’s network.
Note: As of November 1, 2023, there’s now one simple health care reimbursement form for you to use for medical and behavioral health services.
You may need assistance from your provider to complete this form.
To claim reimbursement for your child’s covered dental care received outside the dental network, you’ll want to fill out the Pediatric Dental Claim form (pdf).
To claim reimbursement for approved complementary and alternative medicine services that you have paid for out of pocket (if your plan includes this reimbursement benefit), you’ll want to fill out the Complementary and Alternative Medicine Reimbursement form.
Other insurance coverage forms
To coordinate medical or dental benefits for members covered by another health, dental or Medicare insurance plan, you’ll want to complete the Coordination of Benefits questionnaire.
To ensure that a claim for an injury or illness resulting from an accident, such as a slip and fall, is processed correctly, simply complete the Insurance, Liability and Recovery questionnaire.
Authorization forms
You’ll want to fill out the Member authorization to release PHI form (pdf). This form allows you to authorize Harvard Pilgrim to release/disclose certain protected health information (PHI), according to the terms you specify.
You’ll want to fill out the Confidential Exchange of Information form (pdf). This form allows behavioral health practitioners involved in your care to release health information to other health providers, according to the terms you specify.
You’ll want to fill out the Designation of Representative form. This form allows you to authorize an individual to discuss and make decisions related to your health care and coverage.
You may need assistance from your provider to complete this form.
In order to verify your dependent’s eligibility as a disabled adult — which includes authorization to obtain protected health information— you’ll need to fill out the Disabled Adult Dependent Verification form (pdf).
You may need assistance from your provider to complete this form.
To allow Harvard Pilgrim representatives to speak to a parent about the health coverage and care of their dependent (under age 18) when parent is not listed on that minor’s policy, a Statement of Parental Rights form (pdf) will need to be completed.
If you are the Personal Representative (e.g., health care proxy, power of attorney, etc.) of a member, please complete and submit the Personal Representative Cover Form with your legal documentation in order to be documented in Harvard Pilgrim’s system
Medicare plan forms
Access all the Medicare Advantage Stride forms you need — enrollment, reimbursement, prescription drug, billing, representative designation, privacy and more.
Access all the Medicare Supplement Plan forms you need — additional health insurance coverage, accident/injury questionnaire, authorizations, reimbursement, claim, representative designation and more.
Reimbursement program forms
Claims forms
Please fill out the Health Care Reimbursement Claim Form to request reimbursement for out-of-pocket costs that you paid for covered medical, hospital and behavioral health services. Use the Prescription Drug Reimbursement Claim form (pdf) to request reimbursement for out-of-pocket costs that you paid for covered prescription medications.
You may need assistance from your provider to complete this form.
For HMO, POS and PPO plans, to claim reimbursement for prescription medications covered under your plan that you have paid for out of pocket, you’ll want to complete the Prescription Drug Reimbursement Claim form (pdf).
To claim reimbursement for travel expenses that are primarilly for and essential to covered services that are restricted or prohibited in your state of residence as a result of state law, you’ll want to fill out the Travel Benefit Reimbursement form.
You may be eligible to claim reimbursement for a COVID-19 at-home test that you have paid for out of pocket, check eligibility and find instructions on our COVID-19 testing and coverage page.
Please fill out the Health Care Reimbursement Claim Form to request reimbursement for covered medical, hospital and behavioral health services you received from outside your plan’s network.
Note: As of November 1, 2023, there’s now one simple health care reimbursement form for you to use for medical and behavioral health services.
You may need assistance from your provider to complete this form.
To claim reimbursement for your child’s covered dental care received outside the dental network, you’ll want to fill out the Pediatric Dental Claim form (pdf).
To claim reimbursement for approved complementary and alternative medicine services that you have paid for out of pocket (if your plan includes this reimbursement benefit), you’ll want to fill out the Complementary and Alternative Medicine Reimbursement form.
Other insurance coverage forms
To coordinate medical or dental benefits for members covered by another health, dental or Medicare insurance plan, you’ll want to complete the Coordination of Benefits questionnaire.
To ensure that a claim for an injury or illness resulting from an accident, such as a slip and fall, is processed correctly, simply complete the Insurance, Liability and Recovery questionnaire.