Forms & Document Library

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Manage Your Benefits

There are a number of forms and documents that can help you manage your benefits. These forms can be downloaded and printed using Adobe Acrobat® software. If Acrobat® is already installed on your machine, you can click on any one of the links below to immediately access the form.

Forms & Documents Library

Brand Exception
PDF | 16 kb
Prescription Drug Brand Exception Request Form
Claim Form - Medical
PDF | 218 kb
Medical Claim Form
Claim Form - Prescription, Retail Pharmacy
PDF | 80 kb
Prescription Drug Claim form for prescriptions obtained from a retail pharmacy
Claim Form - Prescription, Mail Order
PDF | 100 kb
Caremark Mail Order Service Claim Form
Claim Form - International
PDF | 1.5 mb
Medical claim form for services received outside the United States
Claim Form - Dental
PDF | 274 kb
Dental Claim Form (MHBP Dental Plan only)
Coordination of Benefits (COB)
PDF | 350 kb
Use this form to update us with information about other health insurance coverage you may have
Dependent Enrollment Form
PDF | 150 kb
Use to add or reinstate dependents under age 26
Dentist Nomination
PDF | 304 kb
Nominate your Non-Network dentist to join MHBP's dental provider network (MHBP Dental Plan only)
Health Care Provider Nomination
PDF | 132 kb
Nominate your Non-Network health care provider to join MHBP's provider network
HRA Direct Deposit
PDF | 61 kb
HRA Direct Deposit Form
HRA Reimbursement
PDF | 77 kb
HRA Reimbursement Form
HSA Authorization
PDF | 358 kb
HSA Authorization/Enrollment Form
Lab Reminder
PDF | 1 mb
Lab Savings Program Reminder Card Form
Member Rights & Responsibilities
PDF | 118 kb
MHBP Member Rights and Responsibilities
Notice of Privacy Practices
PDF | 140 kb
MHBP's policy and practices related to your protected health information
SBC - 2017 Consumer Option
PDF | 283 KB
Summary of Benefits and Coverage, 2017 Consumer Option
SBC - 2017 Standard Option
PDF | 283 KB
Summary of Benefits and Coverage, 2017 Standard Option
SBC - 2017 Value Plan
PDF | 282 KB
Summary of Benefits and Coverage, 2017 Value Plan
SBC Glossary
PDF | 90 kb
Summary of Benefits and Coverage Glossary
Transplant-related Travel
PDF | 240 kb
Travel Reimbursement Request - Aetna Institute of Excellence Transplant Network only
Urine Drug Testing Policy
PDF | 42 kb
MHBP Urine Drug Testing Coverage
Wellness Incentive Account Reimbursement Form
PDF | 96 kb
Complete and return this form to receive reimbursement from your Wellness Incentive Account

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