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) |
Johns Hopkins HealthCare Authorization for use and disclosure of Protected Health Information(PHI). |
| JH Bayview Medical Center JHH/JHHSC |
Dependent Care Account | 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 JHHC 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 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 |
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. |
