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Medi-Pak Supplement

General Medi-Pak Supplement documents

Medicare Eligible On or After 01/01/2020 Application

Medicare Eligible prior to 01/01/2020 Application

Member bank draft forms

If you have individual coverage and a monthly premium, you can pay it through a pre-authorized bank draft. To get started, choose a bank draft form below based on your plan type.


If you receive a paper bill after you submit your bank draft form, then we are still processing your auto-draft request. You will need to use one of the other payment options to pay your bill. Your bank draft should be effective the following billing period once your auto-draft form is processed. If you have any questions please call the phone number listed on your bill or the back of your Member ID card.

Claim forms

We want to pay your eligible claims as fast as possible, so use these forms to submit claims.

Privacy forms

These printable forms allow you to exercise your privacy rights in the most efficient manner. By printing, completing and sending these forms to the Privacy Office, your request will be processed efficiently because we will have the information needed to fulfill the request.

Other forms

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Last updated 10/01/2022