Member Downloads

English 

• 1095-B Correction/Coverage Discrepancy Form
• Access to PHI Request Form
• Account Passcode/PIN Request Form
• Accounting of PHI Disclosures Request Form
• Amendment of PHI Request Form
• Chronic Care/Condition Management Referral Form
• Claim Reimbursement Form
• Confidential Communications Request
• Continuity of Care Form
• Declaration of Disability for Over Age Dependents
• Grievance Form
• HIPAA Use and Disclosure of Health Information
• HMO Help Center Complaint
• Individual Enrollment Application Form - Supplement
• Individual Termination Form
• Non-Registered Domestic Partner Form for Individual/Family Plans
• Notice of Language Assistance (NOLA)
• Privacy Complaint Form
• Rate Filing Disclosure Form - Individual
• Rate Filing Disclosure Form - Small Group
• Rate Filing Disclosure Form - Large Group
• Request for Termination Review Form
• Restriction to Use or Disclosure of PHI

Medicare Members:

• If you want to submit for reimbursement for medical expenses for: an out of network provider, services received outside of the country, use the following form:
  • Medicare Medical Claim Reimbursement Form
     
• If you traveled for a transplant and have expenses to submit for reimbursement, use the following form:
  • Medicare Transplant Travel Reimbursement Form

Spanish

• 1095-B Correction/Coverage Discrepancy Form
• Access to PHI Request Form
• Account Passcode/PIN Request Form
• Accounting of PHI Disclosures Request Form
• Amendment of PHI Request Form
• Chronic Care/Condition Management Referral Form
• Confidential Communications Request
• Continuity of Care Form
• Declaration of Disability for Over Age Dependents
• Grievance Form
• HIPAA Use and Disclosure of Health Information
• HMO Help Center Complaint
• Individual Termination Form
• Non-Registered Domestic Partner Form for Individual/Family Plans
• Notice of Language Assistance (NOLA)
• Privacy Complaint Form
• Rate Filing Disclosure Form - Individual
• Rate Filing Disclosure Form - Small Group
• Rate Filing Disclosure Form - Large Group
• Request for Termination Review Form
• Restriction to Use or Disclosure of PHI

Medicare Members:

• Si desea solicitar el reembolso de los gastos médicos de: un proveedor fuera de la red, servicios recibidos fuera del país, utilice el siguiente formulario:
  • Medicare Medical Claim Reimbursement Form
     
• Si viajó para un trasplante y tiene gastos que presentar para reembolso, use el siguiente formulario:
  • Medicare Transplant Travel Reimbursement Form

• MyWHA Basics: Guide to Managing Your Health Plan Online
• Coverage Options for American Kidney Fund Grant Recipients

• MyWHA Basics: Guide to Managing Your Health Plan Online