Forms and Documents

Prior to downloading your form, please note the following:

  • Forms listed here are in Portable Document Format  (PDF) . You will need Acrobat Reader plug-in to open PDF files. Please visit Adobe website to download the plug-in.
  • After you click on any form, you will be able to see the purpose and requirements of the document. Please take time to read these requirements to check if they are applicable to you. Some of the documents presented here may not apply to you depending on your situation.
  • Some forms may be available for electronic filing.
  • The forms below are in alphabetical order contained within categories.
Last updated: 10/1/2013 12:00:00 PM
Copyright Aultman Health Foundation
AultCare Information Systems
 
 
Claim Forms
Form Name Description
form image AultChoice - HRA Request reimbursement from your AultChoice HeathCare Reimbursement Arrangement (HRA).
form image Claim Application Authorize payment of medical benefits to physician or supplier for described services.
form image Dental Claim Form Form & Instructions for filing a Dental Claim.
form image ECS Guide ECS Guide
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Miscellaneous
Form Name Description
form image Access Request Form Request access to copy or inspect certain aspects of your protected health information..
form image Access Request Form Request access to copy or inspect certain aspects of your protected health information..
form image Amendment Request Form Request corrections or amendments to your protected health information.
form image Confidential Communication Request Form This form provides you with general information of your right to request confidential communications from your Health Plan.
form image Designation of Authorized Representative Authorize disclosure of protected health information to a third party.
form image Restrict Protected Health Information Request restrictions on uses and disclosures regarding your protected health information (member request).
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Member Forms
Form Name Description
form image Accident Questionnaire Form to provide additional information regarding claims due to an accident or injury.
form image Aultra Request for Review by the Ohio Department of Insurance Use this form if you disagree with our decision to deny your request for External Review.
form image Aultra Treating Physician Certification for Experimental or Investigational ABD You may have your provider complete this form if your request for benefit determination has been denied as Experimental or Investigational. (We do not require the completion of this form, but provide it for your convenience. Your provider must certify to us in writing that your request is of an expedited nature before we will proceed with an expedited appeal.)
form image Aultra Treating Physician Certification Internal Appeal and or External Review You may have your provider complete this form if your request for benefit determination has been denied as Experimental or Investigational or not Medically Necessary. (We do not require the completion of this form, but provide it for your convenience. Your provider must certify to us in writing that your request is of an expedited nature before we will proceed with an expedited appeal.)
form image External Review Procedures Summary An explanation of the new External Review procedure for all Insured and Public Employer Plans effective 01/01/2012.
form image External Review Request Form Use this form to request an External Review after you have exhausted your internal appeal process with us, unless your request is expedited. (For Insured and Public Employer Plans)
form image Flexible Spending Claim Form (Dependent) Instructions and form to submit Dependent Care Account claim for reimbursement of dependent care expenses.
form image Flexible Spending Claim Form (Medical) Instructions and form to submit Health Care Spending Account claim for reimbursement of medical expenses.
form image Internal Appeal Request Form Use this form to request an internal appeal. You may also submit your appeal in writing to us.
form image Other Coverage Information Form Notify Aultra of Health insurance coverage
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Pharmacy
Form Name Description
form image Aultra Prescription Assistance Prescription assistance programs available locally and nationally. This is not meant to be an all-inclusive list. These programs are not associated with Aultra and or your benefits and are for informational purposes only.
form image Aultra Step Therapy This is a brief explanation of the step therapy program.
form image Quantity Limits Quantity Limitations on the amount of medication covered.
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Privacy/HIPAA
Form Name Description
form image Accounting Request Form Receive an accounting of any disclosures made by Your Health Plan of your health and medical information.
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