July 4, 2009  Forms - Provider member | provider | advisor | plan sponsor Claim Forms Special Authorization Forms Administration Forms Specialized Forms/Questionnaires To print and/or view a form, please click on a link below . To save to your hard drive for viewing and/or printing at a later time, right-click on the link, click "Save Target As", and select where you want to save the file on your hard drive. Indicates a secure file, downloadable by authorized users only. Passwords will be changed regularly for security reasons. If you are a provider and wish to view the file, or believe you may be using an old password, contact ClaimSecure for access.   Note: Some forms require Adobe Acrobat to view. Click below to download Adobe Acrobat Reader:  Claim Forms Form Name Size Format Description Dental   237KB PDF Form is to be completed when submitting a dental claim for reimbursement. Be sure to include an original receipt along with completed claim form. Drug   161KB PDF Form is to be completed when submitting a drug claim for reimbursement. Be sure to include an original receipt along with completed claim form. Health Service Spending Account (HSSA)   132KB PDF Form is to be completed when submitting a HSSA claim for reimbursement. Be sure to include an original receipt along with completed claim form. Hospital   77KB PDF Form is to be completed when submitting a hospital claim for reimbursement. Be sure to include an original receipt along with completed claim form. Extended Health Care   168KB PDF Form is to be completed when submitting a major medical claim for reimbursement. Be sure to include an original receipt along with completed claim form. Vision   101KB PDF Form is to be completed when submitting a vision claim for reimbursement. Be sure to include an original receipt along with completed claim form. back to top  Special Authorization Forms Form Name Size Format Description Drug list   168KB PDF List of drugs that may be classified as “Requires Special Authorization” by the plan sponsor. back to top  Administration Forms Form Name Size Format Description Pharmacy Provider Agreement and Information   118KB PDF Form and Agreement to be signed by pharmacy in order to connect and transmit real time drug claims to our facility. Provider connectivity manual   56KB PDF User guide to assist pharmacies on how to connect and transmit real time drug claims to our facility. back to top  Specialized Forms/Questionnaires Form Name Size Format Description Nursing Care Assessment Form   176KB PDF Questionnaire is to be completed when submitting a Nursing Care estimate. Be sure to complete all required information and submit an estimate, prior to approval. Wheelchair Rental Questionnaire   178KB PDF Questionnaire is to be completed when submitting a Wheelchair estimate. Be sure to complete all required information and submit an estimate, prior to approval Hospital Bed Assessment Form   150KB PDF Questionnaire is to be completed when submitting a Hospital Bed estimate. Be sure to complete all required information and submit an estimate, prior to approval Custom Knee Brace Questionnaire   126KB PDF Questionnaire is to be completed when submitting a Custom Knee Brace estimate. Be sure to complete all required information and submit an estimate, prior to approval back to top