Member Forms
General Instructions:
- Each form here contains a brief description to help you determine which one(s) you may need to use.
- Please read each form carefully as additional instructions may apply
- Most of our forms are available in multiple formats - please choose which format works best for you.
- Many of our PDF forms allow electronic signatures. For information on how to sign a PDF form electronically, click here.
- Please note that if you send us the information (such as a completed form) through unsecured email (for example, Gmail, Yahoo Mail, Hotmail, etc.), we cannot guarantee that your protected health information (PHI) is secure. Depending on what you need to send us, we provide other secure methods of submission, such as our member portal and DocuSign. Please choose the submission method you are most comfortable with.
Over-the-Counter (OTC) COVID Test Reimbursement Claim Form |
Member Reimbursement Claim Form |
Authorization to Disclose Protected Health Information (PHI) Form |
***Please read the following before filling out this form.*** Most employers are covering OTC COVID test reimbursement under the pharmacy plan, not under the medical plan. You can find your pharmacy plan's Customer Support phone number on the back of your member ID card. In order to prevent delays, we strongly recommend that you check with your pharmacy plan before submitting a reimbursement request to us, your medical plan administrator. If you know or believe that OTC COVID test reimbursement is covered under your medical plan, however, please use this form: Complete Online or Download PDF |
Complete Online or Download PDF Do not use this form to submit for reimbursement of COVID-19 over-the-counter tests purchased on or after Jan 15, 2022 Request reimbursement for medical, dental, or vision services that were rendered by a provider who “doesn’t accept [your] insurance” or in other words, is out of network. Click here to read more about submitting a claim. |
Complete Online or Download PDF |
International Claim Form |
Other Health Insurance Coverage Form |
Request for Confidential Communication Form |
Download PDF Note: If your services were rendered on a cruise ship, please use the Member Reimbursement Claim form. |
Complete Online or Download PDF |
***Please fill out this form only if you believe you’re in danger or you could possibly be in danger.*** Use this form to ask that RGA not share your Protected Health Information (PHI) with the person who pays for your insurance. This form is generally used if releasing your PHI to the plan subscriber (the person whose name appears as the "employee" on your RGA insurance ID card) could affect your safety. |
Privacy Complaint Form |
Member Appeal Submission Form |
Medical Travel for Steerage Request Form |
Complete Online or Download PDF |
Complete Online or Download PDF |
Download PDF |