Description:
Online form completed by a health plan member requesting medical insurance coverage for themselves and/or another (dependent, for example).
This form includes the following features:
- Wizard Pages - Longer forms are separated into multiple pages for ease of use. Page navigation guides the user from one section to the next.
- Date Selector - The user can type a date in the entry field or select a date by clicking the calendar icon.
- Dynamic Sections - Based on user input, these become visible to request additional information from the user.
- Attachments - The user can attach files to the form and view attachments.
- Submission Page - Appears after the user clicks the "Submit" button. The user is informed that the form has been submitted and is taken to the step in the request workflow.
Support information
Download site