Member Forms
Important forms for members.
Find the right forms for your plan.
- 2027 NationsBenefits Dental Claim Form
- 2027 NationsBenefits Dental Reimbursement Form
- 2026 Dental Claim form
- 2027 HMO Paper Prescription Drug Coverage Determination Request – English | Spanish
- 2026 HMO Paper Prescription Drug Coverage Determination Request – English | Spanish
- 2027 HMO Paper Prescription Drug Coverage Redetermination Request – English | Spanish
- 2026 HMO Paper Prescription Drug Coverage Redetermination Request – English | Spanish
- 2027 Mail Order Pharmacy Form
- 2026 Mail Order Pharmacy Form
- 2027 Online Medicare Prescription Drug Coverage Determination Request
- Member Standing Authorization form
- 2026 Online Medicare Prescription Drug Coverage Determination Request
- Online Medicare Prescription Drug Coverage Redetermination Request
- 2027 Online Medicare Prescription Drug Coverage Redetermination Request
- 2027 Optional Supplemental Enrollment/Disenrollment form
- 2026 Optional Supplemental Enrollment/Disenrollment form
- 2027 Part B Medical Reimbursement Claim form
- 2026 Part B Medical Reimbursement Claim form
- 2027 Personal Medication List – English | Spanish
- 2026 Personal Medication List – English | Spanish
- 2026 PPO Paper Prescription Drug Coverage Determination Request
- 2027 PPO Paper Prescription Drug Coverage Determination Request – English | Spanish
- 2026 PPO Prescription Drug Coverage Redetermination Request – English | Spanish
- 2027 PPO Prescription Drug Coverage Redetermination Request – English | Spanish
- Appointment of Representative form
- SSBCI Verification Form
- Yearly Wellness Checklist
Member Portal
Our member portal gives you 24/7 access to your health plan. View personalized coverage and costs, track expenses, use a digital ID card and more.
