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	UCCI Dental Claim Form	UCCI Dental Claim Form
All	Authorization for Release of Health Information-StandingAuthorization for Release of Health Information-Standing (Spanish)Authorization for Release of Health Information-Unique Authorization for Release of Health Information-Standing (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 AccountDependent Care Claim FormFlexible Spending Account FSA Claim Form WW-LTR-OF-MED-NEC-Wageworks	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.
All	Coordination of Benefits Online Survey	Coordinating benefits with EHP ensures that you receive all of the benefits you are entitled to and helps to control health insurance premium costs.
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.
Broadway Services, Inc. Howard County General Hospital/TCAS JH Bayview Medical Center JHHC JHH/JHHSC JHU Student Health Program Sibley Memorial Hospital	Pharmacy Prior Authorization Request	Your doctor may complete this form to request a prior authorization for your medication OR request exceeding quantity limit or step therapy requirements of your medication.
JH Bayview Medical Center JHHC JHH/JHHSC	Pharmacy Compound Prior Authorization Request	Your doctor may complete this form to request a compounded prescription.
JH Bayview Medical Center JHH/JHHSC JHHC	Pharmacy Formulary Exception Request	Your doctor may complete this form to request a prior authorization for your medication OR request exceeding quantity limit or step therapy requirements of your medication.