Forms & ApplicationsDownload. Print. Repeat as Needed.
On this page you will find some of MedBen’s most commonly used forms that you can download, print and sign. If you have any questions about using and completing these forms, please contact MedBen Customer Service at 800-686-8425 or firstname.lastname@example.org. Plan Administrators are welcome to contact their Account Representative.
Medical and Pharmacy
Notice of Appeal/Designation of Authorization Form – Plan members wishing to file a formal appeal of a disputed claim should use this form. They can also designate another entity to file an appeal on their behalf. (Please print and sign form before sending.)