Forms

Member Forms:

• Dental Claim Form
• Enrollment Application - EDUCATION
• Enrollment Application - NON EDUCATION
• Claims Appeal Representative Authorization
• Medco Home Delivery Form
• Secondary Claim Form
• Opticare Out-of-Network Claim Form – Utah – English
• Opticare Out-of-Network Claim Form – Utah – Espanol
• Opticare Out-of-Network Claim Form – Arizona – English
• Opticare Out-of-Network Claim Form – Arizona – Espanol
• EMI Health Vision Claim Form
• 401(k) Enrollment
• COBRA application
• Authorization to Disclose PHI
• Customer Relations Appeal Form
• Alpine SD Only Medco Home Delivery
• Medco COB Form

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Provider Forms:

• Dental Provider Directory-all plans
• Medical Provider Directory
• Medical Provider Manual
• Outpatient Notification Form
• Dental Provider Manual
• Dental Credentialing Application
• Physician Credentialing Application
• Facility-based Provider Credentialing Application
• TIN Add Form
• TIN Change Form
• Medical Provider Credentialing Application
• Providers Release Form
• IRS W-9

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Employer Forms:

• Education Group Application
• Non-education Group Application

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Broker Forms:

• Education Group Application
• Non-education Group Application

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Disability Forms:

Please return all completed forms to the following address:

DISABILITY DEPT
EMI Health
852 E ARROWHEAD LN
MURRAY UT 84107-5298
FAX (801)269-9734

• Short-term Disability Claim
• Long-term Disability Claim
• Group Life Claim

Some of the forms may contain different return addresses. Regardless of what the forms say, for efficient processing, they should all be submitted to EMI Health. Thank you.