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• Dependent Ver Form 2022

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• Flex Spending Form

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• Vision Claim Form

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• Medical Rx Claim Form

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• HIPAA Member Request To Restrict Uses and Disclosures Of PHI Form AultCare

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• Fillable Form Spanish Accident Questionnaire

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• PCP and Medical Exemption fillable forms 12 28 23 FINAL

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• Generic Incentive Program

  This program assists members with transitioning to a generic equivalent for certain medications when clinically appropriate. An incentive may reduce member cost share. This cost-share adjustment is based on brand name manufacturer assistance programs. Please call AultCare Customer Service at 330-363-6360 or 1-800-344-8858 (TTY 711) for any questions regarding this…

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• Language Access

  Download our PDF English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1- 800-577-5084 (TTY 711). Someone who speaks English can help you. This is a free service. Pennsylvania Dutch Deitsch Die Bekanntmaching gebt…

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• Privacy Policy

  Introduction AultCare Insurance Company (dba AultCare HMO), which is part of an Organized Health Care Arrangement with AultCare Corporation, AultCare Health Insuring Corporation dba PrimeTime Health Plan, and Aultra Administrative Group (AultCare or We) is a Group Health Plan Covered Entity under HIPAA. We’re committed to safeguarding the Privacy and Security of…

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