Member Forms

• Appeals and Grievances Form
• Primary Care Provider (PCP) Change Form
• Designation of Personal Representative Form
• Notice of Privacy Practices
• Prescription Reimbursement Claim Form

Advance Directive:

• Advanced Directive Information Sheet
• State of Maryland Advance Directive Guide & Forms
• CRISP: The State Designated Health Information Exchange (HIE) for Maryland

HIPAA Forms:

• HIPAA Authorization
• HIPAA Revocation

Protected Health Information:

• Request for Access to Protected Health Information (PHI)
• Request for Accounting of Protected Health Information (PHI)
• Request for Amend or Change Protected Health Information (PHI)
• Request for Restriction on Use/Disclosure of Protected Health Information (PHI)