Forms | Montana Health Co

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Member Forms

Click on buttons below to download the forms you need.

Prescription Claim Form

Prescription Claim Form

A form to request reimbursement for out of pocket payment of prescription drugs

Mail Order Prescription Form

Mail Order Prescripton

Medical Claim Form

Medical Claim Form

Special Enrollment Period Validation List

A list of Special Enrollment reasons and verification documents

Member-Designated Representative Form

Information Release

A form to allow MHC to release information to someone else

Monthly Premium Withdrawal Form

A form to authorize monthly payments

Change Form

A form to report changes to off exchange coverage

Appeals

Appellant Rights

Information on your appeal rights.

Click to go to an online form to file an appeal.

Anti-Discrimination Policy

Anti-Discrimination Policy

Preauthorization

All procedure codes requiring preauthorization

Medical Services Electronic Form

Formulary Exception

Behavioral Health/Substance Treatment

Skilled Nursing Facility & Acute Rehab

Home Health Care Services

Consent Allowing You to Appeal on Behalf of your Patient

Prior Authorization Request Form

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