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
 
 
Claim 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 Application for Benefits Form (Claim Form) Claim form to authorize payment of medical benefits to physician or supplier for described services. 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 (Dependent) Instructions and form to submit Dependent Care Account claim for reimbursement of dependent care expenses. 1/1/2009 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
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Miscellaneous
Form Name Description Edition Info Download
form image 270/271 Companion Guide Companion Guide to the ASC X12N Implementation Guides adopted under HIPAA clarifies and specifies the data content being requested when data is transmitted electronically to AultCare. 12/1/2008 download
form image 5010 837 Companion Guide 5010 837 Companion Guide 10/07/2011 download
form image 835 Companion Guide Defines pertinent fields to facilitate 835 Health Care Claim Payment/Advice file processing. 7/28/2010 download
form image 837 companion guide revised – payor connectivity services (PCS) The 837 companion guide indicates what optional data in the HIPAA implementation guide requirements must be met to quickly adjudicate the claim. The companion guide also clarifies additional data information that assists in adjudicating the claim upon receipt. 04/13/2011 download
form image Accounting Request Form Receive an accounting of any disclosures made by Your Health Plan of your health and medical information. 10/06/2006 download
form image Amendment Request Form Request corrections or amendments to your protected health information. 10/06/2006 download
form image Electronic Claim Fact GUIDE Facts you should know about AultCare Electronic Claims. 4/04/2005 download
form image Electronic Eligibilty Companion Guide Instructions on how to request a web account for file transfers and the 834 Companion Guide (Supplements HIPAA Implementation Guide). 9/17/2009 download
form image NPI FAQs Frequently Asked Questions about National Provider ID. 5/14/2007 download
form image Release of Information Authorize disclosure of protected health information to a third party. 1/1/2007 download
form image Team Spirit Award Application Application form for the Team Spirit Award Scholarship to be completed by the Applicant 10/30/2010 download
form image Team Spirit Award Evaluation Evaluation form for Team Spirit Award Scholarship to be completed by the Applicant's Teacher or Counselor 10/30/2010 download
form image Trading Partner Agreement Printable contract to conduct electronic file transfers. 11/05/2008 download
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Newsletters
Form Name Description Edition Info Download
form image AultCare Annual Report 2009 2009 AultCare Annual Report 3/23/2010 download
form image AultCare Member Fall 2010 AultCare Member Newsletter Fall 2010 10/15/2010 download
form image AultCare Member Spring 2010 AultCare Member Newsletter Spring 2010 10/15/2010 download
form image AultCare Results from Cardiocom Program AultCare has been using patient telemonitoring for six years and has, in partnership with Cardiocom, released a white paper entitled, "AultCare Sees Positive Results from Cardiocom Program." 9/13/2010 download
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Policies & Disclaimers
Form Name Description Edition Info Download
form image Web Disclaimer Web disclaimer 1/10/2008 download
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Member Forms
Form Name Description Edition Info 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 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 Other Coverage Information Form Printable form for other coverage information. 2/01/2009 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. 10/27/2010 download
form image Utilization Review Policy Instructions regarding Pre-certification (Pre-approval/Pre-Authorization). 11/03/2008 download
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Pharmacy
Form Name Description Edition Info Download
form image 2012 AultCare Formulary AultCare 2012 Formulary 12/14/2011 download
form image 2012 AultCare Formulary Numbered by Tier AultCare 2012 Formulary 9/29/2011 download
form image Alliance County OE Rates Open Enrollment rates for Alliance County residents. 12/11/2009 download
form image BioScrip FAQ Frequently asked questions regarding BioScrip Mail Service. 7/02/2007 download
form image BioScrip Mail Order Form Printable Mail Service Prescription Drug Program Order Form 1/11/2007 download
form image Carroll County OE Rates Open Enrollment rates for Carroll County residents. 12/11/2009 download
form image Holmes County OE Rates Open Enrollment rates for Holmes County residents. 12/11/2009 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 Open Enrollment - Basic AultCare Basic Open Enrollment plan 1/1/2010 download
form image Open Enrollment - Standard AultCare Standard Open Enrollment plan 1/1/2010 download
form image Open Enrollment Application Printable Open Enrollment Application. 6/28/2010 download
form image Open Enrollment Comparison An outline of the terms of the Basic and Standard benefit plans offered. 12/23/2009 download
form image Patient Brochure BioScrip Patient Brochure contains information on how to get started with BioScrip Pharmacy Services. 5/01/2006 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 Stark County OE Rates Open Enrollment rates for Stark County residents. 12/11/2009 download
form image Step Therapy Program Effective 1/1/2012. This is a brief explanation of the Step Therapy program. 11/23/2011 download
form image Tuscarawas County OE Rates Open Enrollment rates for Tuscarawas County residents. 12/11/2009 download
form image Wayne County OE Rates Open Enrollment rates for Wayne County residents. 12/11/2009 download
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Enrollment
Form Name Description Edition Info Download
form image 2011 AultCare Formulary AultCare 2011 Formulary 9/29/2011 download
form image 2011 AultCare Formulary Numbered AultCare 2011 Formulary Numbered by Tier 9/29/2011 download
form image For You Discount Program Brochure Information regarding AultCare For You Discount Program available to AultCare clients. 11/04/2010 download
form image For You Discount Program Form Form for potential FOR YOU company participants to fill out. 11/04/2010 download
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