Documents and Forms

Below are links to forms to help you manage your benefit plan. Don't see what you're looking for or have a question?
Contact us at 844.388.8268 (TTY 711).


Dental Claim Form

Use this form to request reimbursement of services.

Member Claim Form

Use this form to submit claims and expenses for medical care or a  drug you received under the Essential Advocate PPO and Enhanced Complete PPO plans.

Vision Claim Form

Use this form to request reimbursement for services.

2021 Enrollment Application

This is the individual enrollment form. Please contact Vibra Health Plan if you need information in another language or format (Braille).

Appointment of Representative Form

If you want a friend, relative, your doctor or other provider, or other person to be your representative, print and complete this form and return the signed form to Vibra Health Plan. The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf.

Authorization to Disclose Personal Health Information

This form is used to advise Vibra Health Plan of the person or persons you have chosen to have access to your personal health information.

Coordination of Benefits Form

Use this form to tell us if you have other health insurance besides Vibra Health Plan.

Coverage Determination Form

This form is to send a request for medicare prescription drug coverage determination.

Formulary

The formulary may change at any time. You will receive notice if necessary. To request a printed copy, contact us at 844.388.8268 (TTY 711).

Notice of Privacy Practices

This notice describes how protected health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Part B Step Therapy Drug List 2021

Services needing Pre-Authorization

View this information for information on certain procedures that need to authorized prior to the service to ensure payment is made through your health care benefit.

Summary of Benefits 2021

You can review all the benefits for each plan in one document.

Vibra Health Plan Enhanced Complete PPO Annual Notice of Changes 2021

If you are currently enrolled as a member of the Vibra Health Plan Enhanced Complete PPO there can be changes from year to year. In this coming year, there will be some changes to the plan’s costs and benefits.

Vibra Health Plan Enhanced Complete PPO Evidence of Coverage 2021

Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Vibra Health Plan Enhanced Complete PPO which gives you the details about your Medicare healthcare and prescription drug coverage from January 1 – December 31, 2021.

Vibra Health Plan Essential Advocate PPO Annual Notice of Changes 2021

If you are currently enrolled as a member of the Vibra Health Plan Essential Advocate Coverage PPO there can be changes from year to year. In this coming year, there will be some changes to the plan’s costs and benefits.

Vibra Health Plan Essential Advocate PPO Evidence of Coverage 2021

Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Vibra Health Plan Essential Coverage PPO which gives you the details about your Medicare healthcare and prescription drug coverage from January 1 – December 31, 2021.

Authorization Form

This document should be used by providers to submit their authorization requests for care/service delivery.

Authorization List

This document outlines the authorization requirements that should be referenced by all providers when requesting a service or care delivery.

Facility Change Form

Use this form to submit any changes to your practice.

Physician Change Form

Use this form to submit any changes to your physician.

Provider Manual

Updated October 1, 2020
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