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Contact Us Today: (800) 585-5965

With the right information, you can make more responsible, financial healthcare decisions. We want you to be able to take control of your own healthcare with access to our resources and comprehensive toolkit of forms.

MEDICAL, DENTAL AND VISION CLAIM FORMS

  • Claim Form - Medical
  • Claim Form - Dental
  • Claim Form - Vision
  • Claims Fax Cover Sheet

FLEXIBLE SPENDING ACCOUNT REIMBURSEMENT (FSA)

  • Flex Direct Deposit Form
  • Flex Reimbursement Request Form

PARTICIPANT (INDIVIDUAL & FAMILY) PLAN FORMS

  • Accident Coordination of Benefits Questionaire
  • Third Party Liability Form

EXCHANGE MODEL NOTICES & RIGHTS NOTIFICATION

  • Exchange Model Notice (Coverage Provided)
  • Exchange Model Notice (No Coverage Provided)
  • Exchange Model Notice Sample Cover Letter
  • Women's Cancer Rights Notification
  • Children's Health Insurance Program (CHIP) Notice

MEDICARE DOCUMENTS & INFORMATION

  • Employee Notice Packet (Medicare Part D Creditable)
  • Employee Notice Packet (Medicare Part D Non-Creditable)

PROVIDER PRE-AUTHORIZATION FORMS

  • Retail Pharmacy Prior Authorization Request Form
  • Specialty Pharmacy Medical Request
  • Formulary Exclusion Prior Authorization Form
  • Healthcare Authorization Form

SECURITY/PRIVACY FORMS & DOCUMENTS

  • HIPAA Authorization Form
  • Notice of Privacy Practice

MISCELLANEOUS

  • Summary of Benefits and Coverage Uniform Glossary

IMPORTANT NOTICES

  • Your Rights and Protections Against Surprise Medical Bills
  • Extended Plan Deadlines

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Get in Touch

  • Centrix Benefits Administrators
    817 Bowsprit Rd, Suite 220, Chula Vista, CA 91914
  • Main Number: (800) 585-5965
  • Local: (619) 220-9002
  • Fax: (619) 220-9003

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Benefits Administrators. All Rights Reserved

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