Member Forms

Dental Claim Form: Dental Claim Form 

Please use this form for dental claims, when the claim is not filed through your dentist.

Instructions for completing this form  

Prescription Drug Form: GO-510

Please use the GO-510 form only for prescription drug claims when the claim is not filed through your pharmacist

For Medical Claims, including Medicare: CMS-1500

We are unable to provide a CMS-1500 form on-line, since these forms use a red ink which enables them to be scannable using OCR equipment. This ink cannot be duplicated by regular PC color printers, and therefore, we ask members to please submit pre-printed, red-ink CMS forms, which can be obtained from your local office supply retailers.

You may go out to the site at Centers for Medicare and Medicaid Services (CMS)  and choose CMS-CMS-1500 to view a copy of a proper form.  We stress that a copy of the form printed from their site will not be scannable and will result in delayed processing of your claim.

Instructions for completing this form