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COVID-19 Updates

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

MedCost
Forms

Easy-Access Member Claims Forms

Here are printable claims forms for your convenience. However, it is even easier to submit eForms through your Member account. If you have any questions, please call our Customer Service Contact Center at the number listed on your ID card or access Live Chat.

Requests for enrollment or benefit change forms are made through your company’s benefits administrator or Human Resources department.

Medical And Dental Claim 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. If you purchase an over-the-counter at-home COVID-19 test from a pharmacy, store, or online retailer and you are charged for your test, keep your receipt and submit a claim to the pharmacy benefit manager (PBM) listed on your 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).

Transition of Care

Request continuation of care with a non-network provider.

Adobe Acrobat Reader is required to view/print PDF files. You can download the Reader for free from www.adobe.com.

Additional forms can be found within your secure Member account (Accident Details, Coordination of Benefits and Subrogation). To access these interactive forms, you must be a registered user and be logged in.