Member Forms

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. If you do not have Acrobat Reader, please visit the Adobe website to download the plug-in.

Member Forms

Claim Forms
HIPAA, Guides, & Directives
HIPAA Forms
  • HIPAA Access Request form - Members can use this form to access their insurance Protected Health Information (PHI) from AultCare. Please route this request to the Privacy Coordinator at AultCare.  Please
    allow a 15 day turnaround response time for this request. 
  • HIPAA Amendment Request Form - Members can use this form to request a change to the Protected Health Information (PHI) AultCare has on file.  This can be used if the member has found an error in their PHI.
  • HIPAA Confidential Communication Request Form- Members can use this form to request that their Explanation of Benefits (EOB) or other AultCare communications are confidentially sent to a different address than what is on file or that phone calls are made to a different phone number.  If you feel that harm may be caused if your information is sent to anyone outside of you, please complete the Member Request to Restrict Uses and Disclosures form.
  • HIPAA Designation of Authorized Representative Form
    - Members can use this form to
    designate someone other than you to speak to us on your behalf. Legal documentation (such as a General or Durable Power of Attorney or Guardianship) is required to allow an Authorized Representative to make actual changes on your behalf.
  • HIPAA Member Restrict Uses and Disclosures - Members can use this form to limit who has access to their Protected Health Information (PHI).
Other Coverage Forms
Other AultCare Departments
Appeals & External Review
  • Internal Appeal Request Form - If you disagree with a determination decision about a specific benefit, you have the right to file an internal appeal with AultCare using this form. You may also submit your appeal in writing and include any written comments, documentation, or records relevant to your appeal.
  • 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 it as an expedited appeal.)
  • 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 and you are requesting an expedited appeal or review. (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 it as an expedited appeal.)
  • External Review Request Form - If you disagree with our appeal decision and have exhausted your internal appeal rights, you can request an External Review using this form. (For Insured and Public Employer Plans Only)
  • AultCare Request for Review by the Ohio Department of Insurance -  If we have denied your request for an External Review     and you disagree with our decision, please use this form.
  • External Review Procedures Summary - An explanation of the External Review procedure for all Insured and Public Employer Plans effective 02/2012.