USAble Mutual Insurance Company

Forms for Members

The forms listed on the menu below are for use by members. These forms are in portable document format (PDF). You may print and copy as needed. Note: Some employers use customized forms or electronic systems. Check with your Human Resources office before using one of these forms.

  • Authorized Representative Appointment Form (PDF) Request authorization for someone else to act on your behalf regarding your medical coverage.
  • Individual Request for Accounting (HIPAA) - Coming Soon Make an individual request for account of certain disclosures of Protected Health Information (PHI) for non-treatment, payment or health-care operations purposes by USAble Administrators.
  • Individual Request Not to Use or Disclose PHI (HIPAA) - Coming Soon Request not to use or restrict health information or to end restriction on use or disclosure of health information maintained by USAble Administrators.
  • Individual Request to Correct or Amend a Record (HIPAA) - Coming Soon Make an individual request to correct or amend a record maintained by USAble Administrators.
  • Individual Request to Inspect Health Information (HIPAA) - Coming Soon Make an individual request to inspect health information maintained by USAble Administrators.
  • Mail Service Order Form (PDF) For those members who have a mail-order drug benefit.
  • Medical Claim Form (PDF) Submit claims not filed by a doctor or hospital.
  • Physician Incapacity Letter (PDF)
  • Request for Confidential Communication (HIPAA) - Coming Soon Request confidential communication of Protected Health Information (PHI) from USAble Administrators.
  • Subscriber's Incapacity Form (PDF)