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	Member Forms	When to Use this Form
Administration Forms	Authorization to Use or Disclose Protected Health Information Coordination of Benefits Form Dependent Certification Form, Massachusetts Family en espanol Dependent Certification Form, Rhode Island Family Disabled Dependent Evaluation Form Michelle's Law Physician Certification Form Prenatal Questionnaire Form	HIPAA privacy form to allow sharing of your health information To coordinate your Tufts Health Plan coverage with additional health care coverage a Verify an covered dependent age 19 or over as a full-time student a Completed by you and your dependent's physician Used to certify medical necessity for Michelle's Law coverage eligibility For enrollment in Tufts Health Maternity Program
Pharmacy Forms	Prescription Reimbursement Claim Form Prescription Reimbursement Claim Form, purchased in a foreign country Prescription Mail Order Form, CVS/Caremark The Med List Form	For prescriptions purchased in USA For prescriptions purchased in a foreign country When ordering a new mail-order prescription To keep a written record of your medications
Reimbursement Forms	Fitness Reimbursement Form Medical Reimbursement Claim Form Medical Reimbursement Claim Form Medical Claim Profile Request Form	Plan specific, does not apply to all members For HMO, POS, EPO, & PPO members For PPO members with PHCS provider network Obtain a detailed history of your claims

Documents