Member Forms

Member Forms

 

EHP Employer Group	Form	Description
All	Medical/Vision Claim Form	Johns Hopkins Employer Health Programs Medical / Vision Claim Form
Broadway Services, Inc. JH Bayview Medical Center JHH/JHHSC JHU Student Health Program Howard County General Hospital/TCAS Sibley Memorial Hospital Suburban Hospital	Delta Dental Claim Form	Delta Dental Claim Form
All	Authorization for Release of Health Information – Standing Authorization for Release of Health Information – Standing (Spanish) Authorization for Release of Health Information – Unique Authorization for Release of Health Information – Unique (Spanish) Representation of Responsibility for Minor Child Representation of Responsibility for Minor Child (Spanish)	Johns Hopkins HealthCare Authorization for use and disclosure of Protected Health Information(PHI).
Broadway Services, Inc. JH Bayview Medical Center JHH/JHHSC JHU Student Health Program Howard County General Hospital/TCAS Sibley Memorial Hospital Suburban Hospital	Dependent Care Account Dependent Care Claim Form Flexible Spending Account FSA Claim Form Wageworks Letter of Medical Necessity	Johns Hopkins HealthCare form to initiate FSA proceedings.
Broadway Services, Inc. JH Bayview Medical Center JHH/JHHSC JHU Student Health Program Howard County General Hospital/TCAS Sibley Memorial Hospital Suburban Hospital	Pharmacy Prescription Reimbursement Standard Claim Form	Pharmacy reimbursement form for primary prescription coverage.
Broadway Services, Inc. Howard County General Hospital/TCAS JH Bayview Medical Center JHH/JHHSC JHU Student Health Program Sibley Memorial Hospital Suburban Hospital	Pharmacy Prescription Reimbursement Secondary Claim Form	This form should be used ONLY if you are submitting claims for secondary prescription coverage.
Broadway Services, Inc. Howard County General Hospital/TCAS JHH/JHHSC JH Bayview Medical Center JHU Student Health Program	Pharmacy Mail Order Prescription Claim 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	Pharmacy Foreign Claims Form	This form is used to provide direct reimbursement for prescriptions that were purchased outside the United States.
All	Primary Care Provider Change Form	Complete this form to change your Primary Care Provider.