Forms for employees of

• Medical/Vision Claim Form

• SuperiorVision Claim Form

• Delta Dental Claim Form

• Authorization for Release of Health Information – Standing

  Johns Hopkins Health Plans Authorization for use and disclosure of Protected Health Information(PHI).

• Authorization for Release of Health Information – Standing (Spanish)

  Johns Hopkins Health Plans Authorization for use and disclosure of Protected Health Information(PHI).

• Authorization for Release of Health Information – Specific Request

  Johns Hopkins Health Plans Authorization for use and disclosure of Protected Health Information(PHI).

• Authorization for Release of Health Information – Specific Request (Spanish)

  Johns Hopkins Health Plans Authorization for use and disclosure of Protected Health Information(PHI).

• Representation of Responsibility for Minor Child

  Johns Hopkins Health Plans Authorization for use and disclosure of Protected Health Information(PHI).

• Representation of Responsibility for Minor Child (Spanish)

  Johns Hopkins Health Plans Authorization for use and disclosure of Protected Health Information(PHI).

• Dependent Care Reimbursement Form

  Johns Hopkins Health Plans form to initiate FSA proceedings.

• FSA/HRA Medical Necessity Form

  Johns Hopkins Health Plans form to initiate FSA proceedings.

• FSA/HRA Reimbursement Form

  Johns Hopkins Health Plans form to initiate FSA proceedings.

• Pharmacy Prescription Reimbursement Standard Claim Form

  Pharmacy reimbursement form for primary prescription coverage.

• Pharmacy Prescription Reimbursement Secondary Claim Form

  This form should be used ONLY if you are submitting claims for secondary prescription coverage.

• Pharmacy Mail Order Prescription Claim Form

  Used to order prescriptions authorized by doctor’s signature. All medicines in this order will be sent in the same package to the address provided.

• Pharmacy Foreign Claims Form

  This form is used to provide direct reimbursement for prescriptions that were purchased outside the United States.

• Primary Care Provider Change Form

  Complete this form to change your Primary Care Provider.

No forms found.