Orchard - Unchanged

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General Forms

Authorized Representative Form PDF file

File an Appeal Form PDF file

Medical Preauthorization Forms

Nominate a Provider Form PDF file

Records Release Consent Form PDF file

Release Health Information Form PDF file

Self-Pay Medical Claim Form PDF file

Pharmacy Forms

Express Scripts Home Delivery Order Form PDF file

Coordination of Benefits/Direct Claim Form PDF file

Diabetes Savings Program Form PDF file

Pharmacy Preauthorization Forms

Submit Direct Claim Form Electronically

Wellness Rebate Forms

First Steps ($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