You'll find the main forms you may need as a Network Health Extend™ member here.
- Network Health Authorized Representative Form (PDF)
Use this form to allow a person to act on your behalf regarding a specific Grievance, Grievance Decision Review, Internal Appeal, or External Review.
- Network Health Extend EXTRAS Form (PDF)
Use this form to order FREE bike helmets, home safety kits, and/or child ID kits.
- Network Health Extend Reward Form (PDF)
Use this form to get a reward for taking steps to stay healthy, like getting a yearly checkup (for everyone), getting required immunizations (for children), and getting five routine diabetes screenings in one calendar year (for members with diabetes).
- Network Health Extend Reimbursement Form (PDF)
Use this form to get a reimbursement for acupuncture services; gym fees or fitness activities; Weight Watchers registration and program costs; childbirth, newborn, and breastfeeding classes; and eyeglasses/contact lenses.
- Permission to Share Protected Health Information (PHI) Form (PDF)
Use this form to let us share your PHI with a person you choose, for example, sharing information related to your HIV/AIDS diagnosis and/or treatment with a member of your family.
- The Medical Security Program (MSP) External Review Request Form (PDF)
Use this form to file for an expedited External Review with an independent agency.