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The following forms are available to view
online or download. These forms are in html or PDF format, and may
require that you have Adobe Acrobat Reader installed. Acrobat Reader
is available as a free download from Adobe. Click
here to get Acrobat Reader. Forms
Address Correction Form To be used to notify your health plan administrator of an address change or correction. Claim Form To be completed by the member and submitted with a detailed bill when the member pays for a medical service out-of-pocket. Conversion Coverage * AmeriCorps Health Benefits Program - Group C1S001290 Upon termination from service with AmeriCorps you may convert to a private plan administered by Celtic Insurance Company. You must submit a completed "Notification of Your Right To Convert" form to Celtic within 30 days of the date you terminate from service. Member Health Care Guide Member Health Care Guide [Spanish Version] This guide describes the health care benefits you are entitled to while serving as an AmeriCorps*VISTA or AmeriCorps*NCCC member. Name Correction Form To be used to notify your health plan administrator of a name change / correction. Other Health Coverage Questionnaire This form must be completed annually by each member to provide information regarding any other health insurance coverage. Personal Representative Form This form is to be used as needed to confirm a member’s permission that the health plan may discuss or disclose their protected health information to a particular person who acts as their Personal Representative. PharmaCare Direct Mail Service Form To receive your prescription(s) by mail complete this form. PharmaCare Direct Member Reimbursement Form PharmaCare Direct Member Reimbursement Form [Spanish Version] To request reimbursement for a prescription that was purchased without the use of your ID card. Pharmacare Prescription and Pharmacy Information Provides information regarding your pharmacy benefits including a list of pharmacies in the network and a list of excluded drug categories. Pre-existing Conditions Letter Pre-existing Conditions Letter (Spanish Version) You should complete the top section of this form and give it to your primary care physician to complete the requested medical information. This is required to document the original date a specific diagnosis was made and is used to establish whether a condition is pre-existing. Release of Information Form This form is to be used as needed to confirm a member’s authorization to release information, which may include the use or disclosure of their protected health information for a particular purpose other than normal claim payment and operations. Waiver AmeriCorps requires all members to enroll in their health plan UNLESS proof of other coverage is submitted. Use this form to waive AmeriCorps health coverage. |
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