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COVID-19 Updates

Go to our COVID-19 resource page for up-to-date information.

Downloadable Forms

Frequently Used Employer Forms

Claims forms are here for your members. If you have questions, please call our Customer Service Contact Center at 1-800-795-1023.

Medical and Dental Claims Forms

If you received care or a bill from an out-of-network provider, use these forms to submit a claim for reimbursement or to request coverage.

The medical claim form should not be used to request reimbursement for over-the-counter at-home COVID-19 tests. Members who purchase an over-the-counter at-home COVID-19 test from a pharmacy, store, or online retailer and are charged for the test should keep their receipt and submit a claim to the pharmacy benefit manager (PBM) listed on their health plan ID card for reimbursement. Go to our COVID-19 resource page for more information.

Authorization to Release Information

Members can use the following forms to give MedCost permission to share information about themselves (or a dependent) with another person or organization.

Spending Account Reimbursement (FSA)

Reimbursement forms related to your flexible spending account (FSA).

Weekly Disability Income Claim

Members use this form for short-term disability claims.

These forms as well as additonal forms for enrollment are located within your secure account.