Forms and Documents

Prior to downloading your form, please note the following:

  • Forms listed here are in Portable Document Format  (PDF) . You will need Acrobat Reader plug-in to open PDF files. Please visit Adobe website to download the plug-in.
  • After you click on any form, you will be able to see the purpose and requirements of the document. Please take time to read these requirements to check if they are applicable to you. Some of the documents presented here may not apply to you depending on your situation.
  • Some forms may be available for electronic filing.
  • The forms below are not in alphabetical order, please look carefully for the form you require.
  • When a form is due to expire, the form and any changes must be reviewed by the management. If a form expires while it is being reviewed, the form may still be used. Once a new edition is available, the website will be updated to ensure only useable editions are listed.
Last updated: 09/12/2011 2:00:00 PM
Copyright Aultman Health Foundation
AultCare Information Systems
 
 
Member Forms
Form Name Description Edition Info Download
form image Accident Questionnaire Form to provide additional information regarding claims due to an accident or injury. 9/3/2009 download
form image Continuation Of Coverage Form For a child who is incapable of self-sustaining employment by reason of mental or physical disability and who has reached the limiting age for dependent children specified in the plan or contract. or For continuation of dependent coverage for college students (FTS) who would otherwise lose eligibility because of a reduction in their full-time class status or a medically necessary leave of absence from school itself. 10/10/2010 download
form image Dental Claim Form Form & Instructions for filing a Dental Claim. 9/3/2009 download
form image Flexible Spending Claim Form (Medical) Instructions and form to submit Health Care Spending Account claim for reimbursement of medical expenses. 1/1/2009 download
form image Full-Time Student Verification Form AultCare verifies dependent information annually to insure that claims are processed according your plan's guidelines. Notification required within 30 days if dependent's full-time status changes dependent does not meet Health Plan guidelines. 5/01/2008 download
form image HMO Member Guide AultCare HMO Member Guide 4/1/2012 download
form image House Bill 1 Attestation Form This form must accompany the enrollment form for Insured and Self Funded public Employer groups when enrolling a dependent ages 26-27 10/10/2010 download
form image Medical/Rx Claim Form Claim form to authorize payment of medical benefits to physician or supplier for described services. 10/10/2010 download
form image Open Enrollment Application Printable Open Enrollment Application. 6/28/2010 download
form image Other Coverage Information Form - AultCare Printable form for other coverage information. 2/01/2009 download
form image Other Coverage Information Form - Timken Printable form for other coverage information 04/26/2012 download
form image PPACA Self Funded Grandfathered Plan Dep Age This form is required for groups with a grandfathered status for enrolling a dependent from the ages of 19-26. This form must accompany a completed enrollment form for the dependent. 05/04/2012 download
form image PPO Member Guide AultCare PPO Member Guide 4/1/2012 download
form image Primary Care Physician Primary care physician (PCP) selection & Medical information release authorization. 3/15/2006 download
form image Sample Explanation of Benefits Consolidated Explanation of Benefits sample with instructions on how to read your CEOB. 8/27/2011 download
form image Utilization Review Policy Instructions regarding Pre-certification (Pre-approval/Pre-Authorization). 11/03/2008 download
form image Vision Claim Form Form & Instructions for filing a Vision Claim. 9/3/2009 download
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Pharmacy
Form Name Description Edition Info Download
form image 2012 AultCare Formulary AultCare 2012 Formulary 4/6/2012 download
form image 2012 AultCare Formulary Numbered by Tier AultCare 2012 Formulary Numbered by Tier 4/6/2012 download
form image Migraine Limitations Limitations on the amount of migraine medication covered. Not all plans are subject to migraine limitations. 5/05/2010 download
form image Prescription Assistance Prescription assistance programs available locally and nationally. This is not meant to be an all-inclusive list. These programs are not associated with AultCare and or your benefits and are for informational purposes only. 7/27/2010 download
form image Step Therapy Program Effective 1/1/2012. This is a brief explanation of the Step Therapy program. 03/26/2012 download
form image Walgreens FAQ Frequently asked questions regarding Walgreens Mail Service. 04/25/2012 download
form image Walgreens Mail Order Form Printable Mail Service Prescription Drug Program Order Form 04/25/2012 download
form image Walgreens Paitent Brochure Walgreens Patient Brochure contains information on how to get started with Walgreens Pharmacy Services. 04/25/2012 download
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Privacy/HIPAA
Form Name Description Edition Info Download
form image Access Request Form download
form image Amendment Request Form Request corrections or amendments to your protected health information. 10/06/2006 download
form image Confidential Communication Request Form download
form image Member Restrict Uses & Disclosures download
form image Release of Information Authorize disclosure of protected health information to a third party. 1/1/2007 download
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Appeals & External Review
Form Name Description Edition Info Download
form image AultCare Request for Review by the Ohio Department of Insurance Use this form if you disagree with our decision to deny your request for External Review. 3/6/2012 download
form image AultCare Treating Physician Certification for Experimental or Investigational ABD You may have your provider complete this form if your request for benefit determination has been denied as Experimental or Investigational. (We do not require the completion of this form, but provide it for your convenience. Your provider must certify to us in writing that your request is of an expedited nature before we will proceed with an expedited appeal.) 3/6/2012 download
form image AultCare Treating Physician Certification for Internal Appeal and or External Review You may have your provider complete this form if your request for benefit determination has been denied as Experimental or Investigational or not Medically Necessary. (We do not require the completion of this form, but provide it for your convenience. Your provider must certify to us in writing that your request is of an expedited nature before we will proceed with an expedited appeal.) 3/6/2012 download
form image External Review Procedures Summary An explanation of the new External Review procedure for all Insured and Public Employer Plans effective 01/01/2012. 3/6/2012 download
form image External Review Request Form Use this form to request an External Review after you have exhausted your internal appeal process with us, unless your request is expedited. (For Insured and Public Employer Plans) 3/6/2012 download
form image Internal Appeal Request Form Use this form to request an internal appeal. You may also submit your appeal in writing to us. 3/6/2012 download
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Directories
Form Name Description Edition Info Download
form image AultCare HMO Provider Directory 2012 2012 AultCare HMO Provider Directory 1/1/2012 download
form image AultCare PPO Provider Directory 2012 2012 AultCare PPO Provider Directory 1/1/2012 download
form image Physician & Hospital Information Validation download
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