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Additional Forms

Direct Claim Form

ACH Letter & Contract
This contract will allow you to pay The Health Plan bill automatically each month with the Automated Payment Program. Deductions on your health care premium will be on the 4th or 5th of each month depending on what region you live in.

Medicare Secondary Payer Form
Required form by the Centers for Medicare and Medicaid Services.

Appointment of Representative Form
This form will allow you to authorize an individual to act as your representative for requesting a coverage determination or an appeal.

Authorization to Disclose Protected Health Information
This form will allow you to authorize an individual(s) to contact The Health Plan and receive information regarding your THP benefit information such as claims, payments, etc.

Individual Request for Access to Protected Health Information
This form will allow you access to inspect and obtain a copy of your health information.

Last Updated: 9/30/2016