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Common member forms and documents

Members

Coordination of Benefits 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.

View the form.

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.

View the form.

Disabled Dependent Certification form

Confirm that new or existing dependents are eligible for coverage under GHP.

View the form.

Medical Claim Reimbursement form

File medical claims.

View the form.

Pharmacy Claims Reimbursement form

Receive reimbursement for prescriptions that you've paid for out of pocket.

View the form.

Request for Independent External Review of an Adverse Benefit Determination form

Request the Pennsylvania Insurance Department to review a healthcare coverage decision made by their plan. For commercial plans only.

View the form.

Providers and suppliers

Medical Paper Claim form for providers

Submit a medical claim to Geisinger Health Plan.

View the form.

Physician Certification for Expedited Review form

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.

View the form.

Manage your health with GHP member portal

Use the member portal to view claims and benefits, find a provider and more.