Forms available for EPMG members. If you have any questions regarding a form, please call Customer Service at 1-800-956-8000. All forms can be opened and downloaded in a PDF format.*

Authorization for the Use and/or Disclosure of Protected Health Information (PHI) form:

This form is used to authorize & give access to your personal health information to a family member or caregiver on your behalf.

Health Information Exchange (HIE) Forms:

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Member Reimbursement:

* Forms are available in Adobe PDF format (printer-ready.) The free Adobe Reader (for PDF format) software can be downloaded by clicking here  

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