Member Forms
Use and Disclose Protected Health Information Authorization Form
Release Confidential HIV-Related Health Information Authorization Form
Use and Disclose Psychotherapy Notes Authorization Form
Patient and Physician Statement Claim Form
Medical Records Transfer Request
Health Club Reimbursement Form
HIP Direct Pay
For assistance in filling out any of the forms, call 1-800-HIP-TALK.
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Use and Disclose Protected Health Information Authorization Form
DownloadA written authorization is required for HIP to share a member's protected health information with anyone, except as permitted by law. This form authorizes the release of general health information and may not be used to authorize the release of HIV-related information or psychotherapy notes that are recorded and kept separately by a mental health professional.
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Release Confidential HIV-Related Health Information Authorization Form
DownloadA written authorization is required for HIP to share a member's protected health information with anyone, except as permitted by law. This form is to be used to authorize the release of confidential HIV-related information.
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Use and Disclose Psychotherapy Notes Authorization Form
DownloadA written authorization is required for HIP to share a member's protected health information with anyone except as permitted by law. This form is to be used to authorize the release of psychotherapy notes that are recorded and kept separately by a mental health professional, documenting the contents of a conversation during a counseling session.
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Patient and Physician Statement Claim Form
DownloadWhen members receive emergency or urgent care outside of the HIP Service area, they should submit a Patient Statement Claim Form. Please read the instructions listed on the form carefully.
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When members with a HIP Pharmacy Rider need to submit a pharmacy reimbursement for out-of-pocket pharmacy expenses, they should submit a Prescription Drug Claim form. Please read the instructions listed on the form carefully.
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Medical Records Transfer Request
DownloadWhen members are changing their Primary Care Physicians (PCPs) from different medical centers or private physician offices, this form should be used. Please read the instructions listed on the form carefully.
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For members who have additional dental benefits beyond HIP's basic preventive dental plan, Medicaid, and Child Health Plus. These members are enrolled in the HIP Prime Dental plan, High Option plan, or the Low Option plan. A dental claim form should be submitted for dental expenses. Please read the instructions listed on the form carefully.
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Health Club Reimbursement Form
DownloadThe health club reimbursement form can only be used by eligible members enrolled in a HIP Classic HMO group, or in a small group HIP Select EPO or HIP Select PPO plan. You must submit evidence of payment in full for a full 12-month membership with the form. Please read the instructions on the form carefully.
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