Important Forms

Overview

File a claim. Order prescription drugs. All the forms you need for communicating with the State Health Plan are listed below.

Enroll in a plan
Learn how to enroll, including instructions and application forms.

Update Your Information
Change your name or address, or add and remove dependents.

Authorize a Representative
Give someone permission to access your health information.

Request Reimbursement
Access various types of claim forms.

Appeal a Decision
Dispute the way a claim was paid.

Order Prescription Drugs
Request that your prescription be filled by mail.

Drug Coverage Review Fax Forms
Request a drug coverage review or appeal a drug coverage denial.

Special Care Pharmacy Fax Form (PDF, 118KB)
Request a specialty medication through Medco.

Flexible Benefit Plan (Section 125) Rejection Form (PDF, 111KB)
Learn how to opt out of the Flexible Benefit Plan, IRS Section 125.

Subrogation
Recover accident-related medical expenditures incurred by the State Health Plan where a third party is liable.

Reimburse the State
Pursue claims paid by the State Health Plan where a third party is liable.

NC Health Choice Forms
Access forms specific to the NC Health Choice for Children program.

Tobacco Cessation Counseling Prescriber Confirmation Form
Use this form to request a copay waiver for generic over-the-counter nicotine replacement therapy patches. For members to be eligible for the copay waiver, health care providers must provide tobacco cessation counseling and complete/fax this form to Medco. Members need a prescription to attain the generic patches.