Top requested forms
Medical claim form
Submit a medical, dental or vision claim when the healthcare provider is not submitting it on your behalf.
Other coverage questionnaire enrollment
Provide information about other healthcare coverage you may have.
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 enroll forms for GAIP students
Policy enrollment and change form
Update member information such as address or remove a dependent from coverage on your plan.
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.
Dependent verification
Use this form to understand the type of documentation you are required to submit when adding dependents for coverage on your plan.
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.
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 (.pdf)
Use when release of personal information is required.
Authorization for release of psychotherapy notes (.pdf)
Allow access to notes made by medical professionals providing psychiatric or psychological services.
Complaint and appeal information (.pdf)
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.