Forms

Below you will be able to access the most up to date Employer and Employee applications,  Claim forms, and websites for Ohio Medical providers.

General Forms:
Universal application
Census form example

www.myuhc.com

Employer Risk Assessment Form
Enrollment Form (2-9 employees)
Enrollment Form (10-50 employees)
Enrollment Form (51-99 employees)
Medical Claim Form
Rx Claim Form
Mail Order Rx Form

On the site you can:

Members:

Find a physician * Create a member account * Print id cards *  view your claims

Employers: www.employereservices.com

View & Administer Member Info* Pay bill * View Statements

UHC Service Hotline: 1-888-UHC-HLP1

www.anthem.com

Employer Risk Assessment Form
Employer Application
Enrollment Form (2-50 employees)
Large Group Enrollment Form (51+ employees)
Mail Order Rx Form
Medical Claim Form

On the site you can:

Members:

Find a physician * Create a member account * Print id cards *  view your claims

Employers:

On the site you can: View & Administer Member Info* Pay bill * View Statements

Anthem Service Hotline: 1-888-290-9159

www.aetna.com

Employer Risk Assessment Form
Employer Application
Enrollment Form (2-50 employees)

On the site you can:

Members:

Find a physician * Create a member account * Print id cards * view your claims

Employers:

View & Administer Member Info* Pay bill * View Statements

Aetna Service Hotline: 1-888-380-7821

www.medmutual.com

Employer Risk Assessment Form
Employer Application
Enrollment Form (2-19 employees)
Enrollment Form (20+ employees)
Fort Dearborn Life Enrollment Form
Rx Claim Form
Mail Order Rx Form
Medical Claim Form
Student Certification Form

On the site you can:

Members:

Find a physician * Create a member account * Print id cards * view your claims

Employers:

View & Administer Member Info* Pay bill * View Statements

MMOH Service Hotline: 1-800-523-8558

www.metlife.com

New Hire Application
Dental Expense Claim

On the site you can:

Members:

Find a dentist * Create a member account * Print id cards * view your claims

Employers:

View & Administer Member Info* Pay bill * View Statements

MetLife Service Hotline: 1-800-ASK-4-MET

www.guardiananytime.com

Dental & Vision Enrollment Form
Life and Disability Enrollment Form
Dental Claim Form
LTD Form
STD Form

On the site you can:

Members:

Find a dentist * Create a member account * Print id cards * view your claims

Employers:

View & Administer Member Info* Pay bill * View Statements

Guardian Service Hotline: 1-888-278-4542

The above companies represent the carriers that we partner with most often.  We are only limited to working with carriers rated A or higher by A.M. Best Company.

Other forms from the carriers listed below as well as any other A rated carrier are available by request, as well as forms required for groups located outside of Ohio.

Lincoln Financial, Reliance, SunLife, CIGNA, Unum, The Hartford, Humana, American Community, Assurant, Principal, and Prudential.

If you have any questions contact me (614) 203-6934.