Forms

Not all forms apply to your benefits plan. Sign in to your account to find specific forms relating to your coverage. If you have any questions about which forms or documents you may need, please call the toll–free number on your health plan ID card.

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Form name
pdf At Home COVID-19 Test Reimbursement Form (UMF0007)
pdf Authorization for Release of Health Information Form (UMF0023)
pdf Baptist Health Quality Network Referral Authorization Form
pdf Continuity of Care Form (UMF0005)
pdf Contraceptive Management Mobile Application Reimbursement Form (UMF0031)
pdf Flexible Spending Claim Form - Dependent Care FSA (UMF0063)
pdf Flexible Spending Claim Form - Health Care FSA (UMF0064)
pdf Health Reimbursement Account (HRA) Form
pdf HSA or FSA Eligible/Ineligible Expense Lists (UM0075)
pdf Member Medical Claim Submission Form (UMF0022)
pdf Member Vision Claim Submission Form (UMF0056)
pdf North Mississippi Health Services Gap Exception Referral Form
pdf Patient Rights Summary
pdf Peer-to-Peer Request Form (UMF0057)
pdf Post-Service Appeals Designation of Authorized Representative (UMF0018)
pdf Post-Service Appeal Request Form (UMF0010)
pdf Pre-determination of Benefits Request Form
pdf Pre-Service Appeals Designation of Authorized Representative (UMF0011)
pdf Privacy Complaint Form
pdf Provider Dental Claim Submission Form (UMF0055)
pdf Provider Medical Claim Submission Form
pdf Provider Remittance Advice (RA) Form (UMF0025)
pdf Request for an Accounting of Disclosures of Protected Health Information
pdf Request for Amendment of Protected Health Information
pdf Request for Confidential Communication Form (UMF0024)
pdf Request for Other Medical/Dental Insurance Information (UMF0033)
pdf Request for Other Medical Insurance Information Form (UMF0021)
pdf Revocation of Request for Confidential Communications of Protected Health Information
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