Forms Center
Check here for important information and forms to help direct your care as a Capital Health Plan member.
If you are a Medicare member, click here for Medicare forms.
- LabCorp Frequently Asked Questions (pdf 370.76 kB)
- LabCorp Maps (pdf 570.67 kB)
- Performance Drug List
Fitness Center Reimbursement
(For more information on the reimbursement program or to see a list of facilities offering discounts to CHP members, check our Health & Fitness Section)
- Fitness Center Reimbursement (pdf 113.73 kB)
General Reimbursement
- General Reimbursement Request Form (pdf 64.62 kB)
Protecting your privacy:
- Notice of Privacy Practices (pdf 119.04 kB)
- Communication Directive (doc 2-21-12 27.36 kB)
- Communication Directive Directions (pdf 30.87 kB)
- Authorization to Disclose Protected Health Information (pdf 29.35 kB)
Assign someone to represent you in accordance with HIPAA regulations:
- Appointed Representative form (pdf 11.11 kB)
Important: These forms are for Capital Health Plan members and enrolled employer groups only. Electronic submission will not be accepted. Members must submit signed forms to their Personnel Office for processing:
- Enrollment form (pdf 519.01 kB)
- Member Status Change Request (pdf 654.29 kB)
Complete and mail the Coordination of Benefits Form to Capital Health Plan within the first 30 days of coverage:
- Coordination of Benefits Questionnaire (pdf 157.76 kB)
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