Forms for Members - Members - Health Advantage

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Forms for Members

These member forms are in portable document format (PDF). You may print and copy as needed. Note: Some employers use customized forms or electronic systems. Please check with your Human Resources office before using one of these forms.

Health Advantage Members

Require Group Administrator's Signature

Prescription Claim Form (882 KB PDF)
Active Employee Application for Out-of-Area Classification (38 KB PDF)
Address Change Form (78 KB PDF)
Change Request Form (34 KB PDF)
Newborn Enrollment Request (34 KB PDF)

Do NOT Require Group Administrator's Signature

Proof of Incapacity Questionnaire (69 KB PDF)
Authorization for Release of Information and Assignment of Authorized Representation (64 KB PDF)
Dependent Application for Out-of-Area Classification (81 KB PDF)
Other Insurance/Coordination of Benefits (COB) (40 KB PDF)
Dependent Student Verification Letter (33 KB PDF)
Primary-Care Physician Selection Letter (35 KB PDF)
Request for Member Social Security Number (42 KB PDF)

Arkansas State Employees/Public School Employees

Do Not Require Group Administrator's Signature

Application For Out-of-Area Classification (34 KB PDF)
Arkansas Employee Benefits Division Forms
ASE/PSE Wellness Benefit (2466 KB PDF)
Other Insurance/Coordination of Benefits (COB) (40 KB PDF)

Other Forms

Bank Draft Form (155 KB PDF)

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