Forms
Cox HealthPlans has provided the following forms to assist you with your healthcare needs.
Authorization for Release of Information - This form is used to designate those people allowed to receive information about your policy.
Coordination of Benefits - This form is used to verify if you or your enrolled dependents have other insurance while insured with Cox HealthPlans.
Direct Payment Individual - This form is used for premium payments to be automatically deducted from your bank account.
Employee Enrollment - HMO - This form is used for enrolling a new employee, adding or terminating dependents, waiving coverage, address and names changes, and special enrollment in an HMO plan. (Must be submit thru your employer)
Employee Enrollment - PPO - This form is used for enrolling a new employee, adding or terminating dependents, waiving coverage, address and names changes, and special enrollment in an PPO plan. (Must be submit thru your employer)
First Health Information/Service Area Map - This provides information regarding the Cox HealthPlans Service area, and access to First Health for nationwide PPO coverage.
Individual Policy Change Form - This form is used to request changes to an existing individual health plan. (Please use the employee enrollment form to make changes to an employer sponsored plan).
Medical Claim Form - This form is used if a member needs to submit a medical claim.
Prescription Claim Form - This form is used if a member needs to submit a prescription claim. (use in both forms and prescription info sections)
PrimeStar Classic Dental Claim Form - This form is used if a member needs to submit a dental claim who has coverage with Security Life.
Self Referral - Care Management - This form is used to request assistance from our Medical Management Team.
If you have any questions or concerns, or need additional assistance, please contact the Member Service Department:
Phone 417.269.2900 or 800.205.7665 Fax 417.269.2949 E-mail members@coxhealthplans.com
Mailing Address
Cox HealthPlans
PO Box 5750
Springfield, MO 65801-5750
Or visit us at
Cox HealthPlans
Kelly Plaza
3200 S. National, Building B
Springfield, MO 65807