Forms for Members - Members - Health Advantage

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Forms for Members

These member forms are in portable document format (PDF). You may print and copy as needed. Note: Some employers use customized forms or electronic systems. Please check with your Human Resources office before using one of these forms.

Arkansas State Employees/Public School Employees

Arkansas Employee Benefits Division Forms: Find the form you need on the Employee Benefits Division Web site.
Other Insurance/Coordination of Benefits (COB) (40 KB PDF): Do you have other insurance? Fill out this form, and let us know.

Group Administrator’s Signature Required

Active Employee Application for Out-of-Area Classification (38 KB PDF): Active Employees of Arkansas-based employer groups that live outside of Arkansas for more than 90 days may have access services covered by Health Advantage on the employee’s group health plan, if approved.
Address Change Form (78 KB PDF)
Change Request Form (58 KB PDF): Use this form to request a change to your current policy, such as name changes, beneficiary change, member termination and more. (Note that this form is used only for groups that submit paper application forms.)
Newborn Enrollment Request (26 KB PDF): A newborn child may be covered from the date of birth if the newborn is enrolled within 90 days of the date of birth.
Prescription Claim Form (882 KB PDF): To make sure eligible claims are paid quickly, please complete and submit this form.
State of Arkansas Continuation of Coverage Election Form (64 KB PDF)

Group Administrator’s Signature NOT Required

Appeal Submission Form (46 KB PDF): Want to appeal a denied claim? Complete and submit this form with any additional information, and your request will be reviewed.
Authorization for Release of Information and Assignment of Authorized Representation (64 KB PDF): Please complete and submit this form to authorize release of information and to assign an authorized representative.
Bank Draft Form (155 KB PDF): Sign up for our free, pre-authorized monthly bank draft and stop writing checks, keeping bills and buying stamps.
Dependent Application for Out-of-Area Classification (113 KB PDF): Dependents of active employees that travel, live or work outside of Arkansas for more than 90 days may be eligible for a temporary out-of-area classification.
Dependent Student Verification Letter (33 KB PDF): Dependents above the maximum dependent age but who are enrolled in an accredited educational institution may be eligible for coverage.
Health Advantage Medical Claim Form (287 KB PDF): We want to pay your eligible medical claim as fast as possible, so please complete and submit this form.
Other Insurance/Coordination of Benefits (COB) Members (40 KB PDF): Do you have other insurance? Fill out this form, and let us know.
Primary-Care Physician Selection Letter (35 KB PDF): If no Primary-care Physician (PCP) was selected or they are no longer in the network, please complete and submit this form to designate a new PCP.
Proof of Incapacity Questionnaire (69 KB PDF): We cover dependent children that have reached the maximum dependent age that are physically or mentally incapacitated and incapable of self-support.
Request for Member Social Security Number (42 KB PDF): A Social Security Number (SSN) is required for all members. If the SSN for a member was not provided at the time of enrollment, please complete this form.