Orchard - Unchanged

Find a Form


General Forms

Nominate a Provider Form PDF file
Self-Pay Medical Claim Form PDF file
File an Appeal Form PDF file
Authorized Representative Form PDF file
Records Release Consent Form PDF file
Medical Preauthorization Forms 
Release Health Information Form PDF file
COVID Test Reimbursement Form PDF file

Pharmacy Forms

Coordination of Benefits/Direct Claim Form PDF file
Submit Direct Claim Form Electronically

Express Scripts Home Delivery Order Form PDF file
Diabetes Savings Program Form PDF file
Pharmacy Preauthorization Forms 

Wellness Rebate Forms

Know & Plan ($50) Rebate PDF file

Next Steps ($50) Rebate PDF file

Other rebates you may be eligible to earn:

FLEX and HRA Forms

FLEX Claim Form - No Grace Period PDF file