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• HIPAA Amend Request Form AultCare

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• HIPAA Access Request Form AultCare

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• AC Short Term DD Form AultCare

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• Dependent Ver Form 2022

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• Flex Spending Form

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• External Review Request Form AultCare

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• Medical Rx Claim Form

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• Dental Claim Form

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• Fillable Form Spanish Accident Questionnaire

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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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