Forms

Not all forms apply to your benefits plan. Sign in to your account to find specific forms relating to your coverage. If you have any questions about which forms or documents you may need, please call the toll–free number on your health plan ID card.

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pdf Applied Behavioral Analysis (ABA) Therapy Requirements (UMF0035)
pdf At Home COVID-19 Test Reimbursement Form (UMF0007)
pdf Authorization for Release of Health Information Form (UMF0023)
pdf Baptist Health Quality Network Referral Authorization Form
pdf Bariatric Surgery & Gastric Bypass Information provider Form (UMF0037)
pdf Behavioral Health ABA Therapy Documentation Requirements (UMF0035)
pdf Chemotherapy Information Request Form (UMF0040)
pdf Clinical Trial Provider Form (UMF0041)
pdf Continuity of Care Form (UMF0005)
pdf CPAP/BIPAP Request Form (UMF0042)
pdf Contraceptive Management Mobile Application Reimbursement Form (UMF0031)
pdf Flexible Spending Claim Form - Dependent Care FSA (UMF0063)
pdf Flexible Spending Claim Form - Health Care FSA (UMF0064)
pdf Genetic Testing for BRCA Mutations (UMF0039)
pdf Genetic Testing Information Request Form (UMF0043)
pdf GUIDE: How to access the UMR Post-Service Appeal Request Form
pdf Health Reimbursement Account (HRA) Form
pdf Home Health Care Visit Request Form (UMF0044)
pdf HSA or FSA Eligible/Ineligible Expense Lists (UM0075)
pdf Infertility Request Form (UMF0045)
pdf Member Medical Claim Submission Form (UMF0022)
pdf Member Vision Claim Submission Form (UMF0056)
pdf North Mississippi Health Services Gap Exception Referral Form
pdf Outpatient Mental Health/Chemical Dependency Information Form (UMF0038)
pdf Peer-to-Peer Request Form (UMF0057)
pdf Post-Service Appeals Designation of Authorized Representative (UMF0018)
pdf Post-Service Appeal Request Form (UMF0010)
pdf Pre-determination Form (UMF0060)
pdf Pre-Service Appeals Designation of Authorized Representative (UMF0011)
pdf Privacy Complaint Form
pdf Provider Dental Claim Submission Form (UMF0055)
pdf Provider Medical Claim Submission Form
pdf Provider Remittance Advice (RA) Form (UMF0025)
pdf Radiation Information Request Form (UMF0046)
pdf Radio Frequency Ablation Request (UMF0047)
pdf Request for an Accounting of Disclosures of Protected Health Information
pdf Request for Amendment of Protected Health Information
pdf Request for Confidential Communication Form (UMF0024)
pdf Request for Other Medical/Dental Insurance Information (UMF0033)
pdf Request for Other Medical Insurance Information Form (UMF0021)
pdf Revocation of Request for Confidential Communications of Protected Health Information
pdf Spinal Surgery Clinical Request Form (UMF0048)
pdf Therapy Information Request Form (UMF0049)
pdf Varicose Veins Clinical Request Form (UMF0050)
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