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.
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