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Coordinating benefits with your other health insurance ensures that you receive all of the benefits you are entitled to and helps to control health insurance premium costs. Please take a moment to update your other health insurance information. Click here.

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Member Forms

Organization

Form

Description

All	Medical / Vision Claim Form	Johns Hopkins Employer Health Programs Medical / Vision Claim Form

JHHSC/JHH JH Bayview Medical Center Broadway Services, Inc.	Dental Claim Form	Johns Hopkins Employer Health Programs Dental Claim Form

All	HIPAA Authorization Form	Johns Hopkins Healthcare Authorization for use and disclosure of Protected Health Information(PHI).

JHHSC/JHH JH Bayview Medical Center	Flexible Spending Account Disbursement Form	Johns Hopkins Healthcare form to initiate FSA proceedings.

JHHSC/JHH JH Bayview Medical Center	Short Term Disability Claim Form	Johns Hopkins Healthcare form to initiate disability claims.

Broadway Services, Inc.	Group Disability Claim Form	Johns Hopkins Healthcare form to initiate disability claims.

AON Broadway Services, Inc. Chester River Hospital Center JHHSC/JHH JH Bayview Medical Center Student Health Program	Prescription Reimbursement Standard Claim Form	Reimbursement form for primary prescription coverage.

AON Broadway Services, Inc. Chester River Hospital Center JHHSC/JHH JH Bayview Medical Center Student Health Program	Prescription Reimbursement Secondary Claim Form	This form should be used ONLY if you are submitting claims for secondary prescription coverage.

AON Broadway Services, Inc. Chester River Hospital Center JHHSC/JHH JH Bayview Medical Center Student Health Program	Mail Order Form	Used to order prescriptions authorized by doctor's signature. All medicines in this order will be sent in the same package to the address provided.

All

Foreign Claims Form

This form is used to provide direct reimbursement for prescriptions that were purchased outside the United States.

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