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.