Forms available for download

Direct Member Reimbursement Form

This form is used to request reimbursement for payment you made directly to a provider.

Direct Member Reimbursement Form

This form is used to request reimbursement for payment you made on a prescription drug, supply or other item.

Member Grievance, Appeal or Concern Form

This is a form used to file a formal grievance or appeal or to share a concern with Antidote.