Forms - Provider may need this

Top Requested Forms

• Medical Claim Form
  Submit a medical, dental or vision claim when the healthcare provider is not submitting it on your behalf.


• COVID-19 OTC home test reimbursement claim form
  Request reimbursement for COVID-19 tests you have paid for out of your own pocket.
  Note: Coverage for COVID home test kits ended on May 11, 2023
  


• Other Coverage Questionnaire Enrollment
  Provide information about other healthcare coverage you may have.


• Health, Allergy & Medication Questionnaire
  Complete this questionnaire for all new mail prescriptions to help protect yourself against potentially harmful drug interactions and side effects.


• Prescription Drug Reimbursement
  Apply for reimbursement of your prescription costs.


• Incident Questionnaire
  Use after sustaining an injury or being involved in an accident.

Pharmacy Forms

• Prescription Drug Reimbursement
  Apply for reimbursement of your prescription costs.


• Secondary Insurance Prescription Drug Claim
  Use for secondary reimbursement of your prescription costs balance where LifeWise is your secondary coverage.

Dependent Enrollment Forms for ISHIP Students

• Student Insurance Policy Enrollment and Change Form UW SHIP
  Update member information such as address or remove a dependent from coverage on your plan.

Dependent Enrollment Forms for GAIP Students

• Student Insurance Policy Enrollment and Change Form UW GAIP
  Update member information such as address or remove a dependent from coverage on your plan.

• Student Insurance UW GAIP Tax Status Declaration
  Use this form to declare your tax status when adding a domestic partner for coverage on your plan. This form is required to add a domestic partner.


• Student Insurance UW GAIP Dependent Verification
  Use this form to understand the type of documentation you are required to submit when adding dependents for coverage on your plan.


• Student Insurance UW GAIP Determine Dependent Status Worksheet
  Use this form to determine the correct tax status to declare on the Tax Status Declaration form when adding a domestic partner for coverage on your plan.


• Student Insurance UW GAIP Marriage Declaration
  Use this form when adding a spouse or domestic partner for coverage on your plan. This is a required form to add these dependents.

Other Coverage Forms

• Other Coverage Questionnaire Enrollment
  Provide information about other healthcare coverage you may have.

Disclosure and Privacy Forms

• Authorization for Release of Healthcare Information and Records
  Use when release of personal information is required.


• Authorization for Release of Psychotherapy Notes
  Allow access to notes made by medical professionals providing psychiatric or psychological services.


• Complaint and Appeal Information
  View LifeWise’s complaint and appeal process.
  
  
• Student Insurance Member Complaint Form
  Use this form to submit a complaint to LifeWise Assurance Company.


• Member Appeal and Authorization
  Request an appeal of a decision and give your permission for another person to submit an appeal on your behalf.


• Disclosure Accounting Request
  Request a record of how we disclose information about you for reasons other than our normal business functions.


• Non-Disclosure Request
  Tell us your requests about sharing your health information.


• Request for Amendment of Records
  Change your official personal information record that we maintain.


• Request for Inspection of Records
  Request certain records we maintain containing your personal information.

Other Useful Forms

Incident Questionnaire
Use after sustaining an injury or being involved in an accident.

Request for Certification of Disabled Dependent
Use to declare that a member is financially responsible for their over-age dependent due to disability.

GAIP Medicare Part D Creditable Coverage Notice 
Information about your current prescription drug coverage and your options under Medicare