Member Forms and Brochures

To view or download a file, click the desired language link. The PDF file will open in a new window or tab of your browser. From there, you can also download or print the file.

Claims

• Medical Claim Form for Group and Individual & Family Plans – English (PDF)
• Medical Claim Form for Group and Individual & Family Plans – En Español (Spanish) (PDF)

Important: Complete a separate form for each member asking for reimbursement for covered services and for each doctor and/or facility. To avoid processing delays, please include the following information with this form:

• Copy of itemized bill showing all services received. Must include name, address, phone number, tax ID number of doctor and/or facility, date of service and all diagnosis and procedure codes.
• Proof of payment for reimbursement requests over $200. "Proof of Payment" includes: a copy of the credit card charge slip or online statement, canceled checks, a bank account statement, cash withdrawal slips, or a cruise ship statement. Note: Invoices are not acceptable proof of payment.
• See the instructions in Section 4 for Foreign Claim Questionnaire for services received outside of the U.S

Other Forms

• Medicare – Medical – MHN Claim Form & Foreign Claim Questionnaire – English (PDF)
• Non-Medicare – Behavioral Health (MHN) – Claim Form – English (PDF)
• IFP and Group Member Grievance Form – English (PDF)
• IFP and Group Member Grievance Form – Chinese (PDF)
• IFP and Group Member Grievance Form – En Español (Spanish) (PDF)
• Appointment of Representative Form CMS-1696

Please explain in detail the circumstances that led to your dissatisfaction with Health Net. Please include the original copy of any claims or bills received which are related to your issue.

• Dental Claim Form – English (PDF)
• Medicare Supplement Plan Claims
• Out-of-Network Vision Claim Form (non-Medicare) – English (PDF)