Member Forms

Title
pdf Prescription Direct Mail Form - This form can be used to have your prescription medication refills delivered directly to your home. You may also submit this request online at https://shopping.drugsourceinc.com/Default.asp or by downloading the DrugSource mobile app at https://shopping.drugsourceinc.com/mobile/rx/. Download
pdf ACH Wire Transfer Form - If you wish to have any reimbursements payable to you to be directly deposited into your account, you may fill out this form, and the information will be securely kept on file. If you need to make a change, simply submit a new form. Download
pdf ACH Wire Transfer Form (español) - Si desea que IMG use Depósito Directo para enviar un reembolso por reclamos médicos u otros gastos médicos reembolsables que usted pago como miembro, debe proporcionar este formulario a IMG y la información será mantenido en un archivo protegido. Si necesita hacer un cambio, sólo tiene que proporcionar un nuevo formulario. Download
pdf Health Benefit Plan Claim Form - If you are covered under the Health Benefit Plan and you have paid for medical services out-of-pocket, this form must be completed and returned to IMG along with a detailed bill and/or payment receipts. Download
pdf Health Benefit Plan Claim Form (español) - Si usted pagó por servicios médicos de su bolsillo y está cubierto por el Plan de Beneficios de Salud, debe proporcionar este formulario a IMG junto con la(s) factura(s) detallada(s) del proveedor y recibos de pago. Download
pdf Healthcare Allowance Medical Reimbursement Form (español) - Si usted pagó por servicios médicos de su bolsillo y está cubierto por el Plan de Subvención para Gastos Médicos, debe usar este formulario para solicitar un reembolso o el pago de los gastos médicos elegibles. Debe proporcionar este formulario a IMG junto con copia de todos los recibos pagados aplicables, declaración(es) del proveedor y Explicación de Beneficios ("EOB") de su compañía de seguros principal. Download
pdf Member Enrollment Form - This form may be used to advise IMG of your enrollment election under the AmeriCorps VISTA health benefit program. This form must be completed upon your initial enrollment into the health benefit program as well as at the start of a new service term. You may also use this form to advise us of a change in your current healthcare coverage status. Please note: You may make your initial enrollment selection online via your MyIMGVISTA account. Download
pdf Member Enrollment Form (español) - Este formulario puede ser usado para proporcionar a IMG su elección de inscripción bajo el Programa de beneficios de salud AmeriCorps VISTA. Este formulario debe ser completado en su inscripción inicial, así como al comienzo de un nuevo período de servicio. También puede utilizar este formulario para informarnos de un cambio en su estado actual de cobertura de atención médica. Tenga en cuenta: También puede acudir a su cuenta en línea de MyIMGVISTA para proporcionar esta información. Download
pdf Privacy and Confidentiality Release Form - In order for IMG to discuss your claims activity with anyone other than you and your physician(s) or provider(s) of service, for example a parent or spouse, you must complete this form and submit it to us. Download
pdf Subrogation Agreement - If you are covered under the Health Benefit Plan and a third-party is considered the cause of or is at-fault for your accident, injury, etc., then this form must be completed, signed and submitted to IMG. Download
pdf Healthcare Allowance Medical Reimbursement Form - If you are covered under the Healthcare Allowance plan, this form must be used to request reimbursement or payment for eligible out-of-pocket medical expenses. You must include a copy of all applicable paid receipts, provider statements, and/or the Explanation of Benefits (“EOB”) from your primary insurance carrier. Download
pdf Injury and Accident Form (español) - Si usted recibió tratamiento médico debido a un accidente o una lesión, tendrá que proporcionar este formulario a IMG con el fin de que podamos procesar los reclamos relacionados. Download
pdf Injury and Accident Form - If medical treatment was sought due to an injury or accident, you will need to submit this form to IMG in order for us to process the related claims. Download
pdf Healthcare Allowance Plan Guide - This guide provides an overview of the AmeriCorps Healthcare Allowance Plan as well as how to use your benefits for reimbursement or payment of covered medical expenses according to your primary insurance carrier. Download
pdf Healthcare Allowance Plan Guide - (español) - Esta guía sirve como resumen del Plan de Subvención para Gastos Médicos de AmeriCorps y también explica cómo acceder a los beneficios para reembolso o pago de los gastos médicos cubiertos según su aseguradora primaria. Download
pdf Health Benefit Plan Guide - This guide provides an overview of the AmeriCorps Health Benefit Plan as well as how to use your benefits for covered medical expenses. Download
pdf Health Benefit Plan Guide - (español) - Esta guía sirve como resumen del Plan de Beneficios de Salud de AmeriCorps y también explica cómo acceder a los beneficios para gastos médicos cubiertos. Download