You'll find the main forms you may need as a Network Health Together member here.
- Consent to Exchange Information Form (PDF)
Use this form to let providers coordinate your medical and behavioral health care.
- 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 Together EXTRAS Form (PDF)
Use this form to order FREE bike helmets, home safety kits, children's car seats, and/or child ID kits.
- Network Health Together Reward Form (PDF)
Use this form to get a reward for taking steps to stay healthy, like getting a yearly checkup.
- Network Health Together Reimbursement Form (PDF)
Use this form to get a reimbursement for childbirth, newborn, and breastfeeding classes; eyeglasses or contact lenses; gym fees or fitness activities; and Weight Watchers registration and program costs.
- 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, use it to share information related to your HIV/AIDS diagnosis and/or treatment with a member of your family.
- Fair Hearing Request Form (PDF)
Use this form to file for an expedited external review with the Board of Hearings.