Types of forms
If you have individual coverage through the Exchange or ARHOME and have a monthly premium, you can pay it through a preauthorized bank draft. To get started, choose a bank draft form below based on your plan type.
- Individual members with Metallic plans (Gold, Silver, Bronze, Catastrophic)
- Individual members with Metallic plans (Gold, Silver, Bronze, Catastrophic) — Spanish version
If you receive a paper bill after you submit your bank draft form, we are still processing your auto-draft request. You will need to use one of the other payment options to pay your bill. Your bank draft should be effective during the following billing period once your auto-draft form is processed. If you have any questions, please call the phone number listed on your bill or the back of your member ID card.
Use these forms to request a change to your current policy, such as name changes, deductible amounts, dependent status and more.
- Active employee application for out-of-area classification
Active employees of Arkansas-based employer groups that live outside of Arkansas for more than 90 days may have access services covered by Health Advantage on the employee’s group health plan, if approved.
- Address change form
- Change request form
Use this form to request a change to your current policy, such as name changes, beneficiary change, member termination and more. (Note that this form is used only for groups that submit paper application forms.)
- Metallic change form
Use this form for all Metallic medical plans (Gold, Silver, Bronze or Catastrophic)
A covered person or an authorized representative can submit written proof of any service, supply, prescription drug, test, equipment or other treatment up to 180 days after the service. In most cases, your healthcare provider will file claims directly with us for services provided. If that does not occur, you may submit the claim directly to us.
Send the completed claim form and written proof of services to the contact information listed on the claim form. For more information, call the customer service number on the back of your member ID card.
Important: Your submission may be returned if it does not comply with our filing and coding policies and procedures. You may request a copy of the claim coding policies and procedures from us or the service provider.
These printable forms help you to efficiently exercise your privacy rights. Simply print, complete and send them to the Privacy Office (listed on the form) so we can process your request promptly with the necessary information.
- Authorization for release form
You have the right to authorize Health Advantage to disclose information regarding claims, payments or other communications to any person or entity.
- Authorization for release of information and assignment of authorized representation - for a minorPlease complete and submit this form to authorize release of information and to assign an authorized representative.
- HIPAA PHI disclosure form
- Request for accounting
You have the right to request a list of any disclosures we have made of your protected health information for purposes other than payment or healthcare operations.
- Request for confidential communications
You have the right to request that we keep communications with you confidential and communicate in an alternate manner.
- Request for restrictions
You have the right to request that we restrict the use of your protected health information for payment and healthcare operations.
- Request to correct or amend record
You have the right to request that any information we created about you be amended if you believe that it is incorrect.
- Request to inspect health information
You have the right to inspect or get a copy of records we maintain about you in a designated record set and which we used to make a decision about you.
- Prescription mail service order form
If your policy has a mail-order drug benefit, use this form to order new and/or refill mail service prescriptions.
- Prescription reimbursement claim form
- Prescription reimbursement claim form - Spanish
- Continuity of care form
- Designation of authorized appeal representative
- Member appeal submission form
- Other insurance/Coordination of Benefits (COB)
- Request to cancel policy
- State of Arkansas continuation of coverage election form
- Proof of incapacity of a dependent - Physician's form
- Proof of incapacity of a dependent - Policyholder's form