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
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)

Authorization of Release of Health Information – Compliance Letter

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).
JH Bayview Medical Center
JHH/JHHSC
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.
JH Bayview Medical Center
JHH/JHHSC
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.
Broadway Services, Inc.
JH Bayview Medical Center
JHH/JHHSC
JHU Student Health Program
Howard County General Hospital/TCAS
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
JHHC
JHU Student Health Program
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
JHHC
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.