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Looking for 2012 Tax-Year information?
CareLink Member Medical Forms- CareLink Personal Representative Designation
- CareLink Authorization to Disclose Protected Health Information
- CareLink Request to Access Protected Health Information
- CareLink Request for an Accounting of Disclosures
- CareLink Request to Amend Protected Health Information
- CareLink Change/Revoke Request
- CareLink Request for Confidential Communications
- CareLink Request to Restrict the Use or Disclosure of Health Information
- CareLink Statement of Disagreement/ Request to Forward Denial of Amendment Request
- browse for:
- Medical Forms
- Pharmacy Forms
- Claim Forms
- Other Documents
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- Authorization to Use or Disclose Protected Health Information
HIPAA privacy form to allow sharing of your health information - Appointment of Personal Representative
Use this form to appoint a person to act on your behalf regarding your Tufts Health Plan benefits and coverage - Coordination of Benefits Form
To coordinate your Tufts Health Plan coverage with additional health care coverage - Disabled Dependent Evaluation Form
- Prenatal Questionnaire Form
For enrollment in Tufts Health Maternity Program
- Authorization to Use or Disclose Protected Health Information
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- Prescription Reimbursement Claim Form
For prescriptions purchased in USA - Prescription Reimbursement Claim Form, purchased in a foreign country
For prescriptions purchased in a foreign country - Prescription Mail Order Form, CVS/Caremark
When ordering a new mail-order prescription - The Med List Form
To keep a written record of your medications
- Prescription Reimbursement Claim Form
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- Fitness Rebate Form
Plan specific, does not apply to all members - Fitness Rebate Form - GIC members
Plan specific, does not apply to all members - Medical Reimbursement Claim Form
For HMO, POS, EPO, & PPO members - Medical Reimbursement Claim Form
For PPO members with PHCS provider network - Medical Claim Profile Request Form
Obtain a detailed history of your claims
Note: Member reimbursements are usually processed within 4-6 weeks of receipt of a completed form.
- Fitness Rebate Form
