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Geisinger provides notice of Nuance’s data security incident

Coordination of benefits
Complete this form if you have a health insurance plan other than Geisinger Health Plan or if you received a letter from the plan’s coordination of benefits department.

Authorized representative statement
Use this form to designate a person to assist with handling your health insurance. You and the person you are authorizing must sign the form.

Disabled dependent certification form
Use this form to confirm that new or existing dependents are eligible for coverage under Geisinger Health Plan.

Medical claim reimbursement form
Use this form to file medical claims.

Medical paper claim form for providers
Providers and suppliers can use this form to submit a medical claim to Geisinger Health Plan.

Pharmacy Claims Reimbursement Form
Members can use this form to be reimbursed for prescriptions that they have paid for out of pocket.

Request for Independent External Review of an Adverse Benefit Determination
Members can use this form to request the Pennsylvania Insurance Department review a healthcare coverage decision made by their plan (commercial plans only). 

Physician Certification for Expedited Review
Providers can use this form to certify that normal timeframes for the review of healthcare coverage decisions would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function.

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