| Title |
|
|
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 IMG AmeriCorps VISTA account.
|
Download
|
|
pdf
Member Enrollment Form (español)
- Puede utilizar este formulario para informar a IMG sobre su elección de inscripción en el programa de beneficios de salud de AmeriCorps. Debe completar este formulario al inscribirse inicialmente en el programa de beneficios de salud, así como al comenzar un nuevo periodo de servicio. También puede utilizarlo para notificarnos cualquier cambio en su situación actual de cobertura de salud. Asimismo, puede realizar su inscripción inicial en línea a través de su cuenta de IMG AmeriCorps VISTA.
|
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. You may also submit this online using your IMG AmeriCorps VISTA account.
|
Download
|
|
pdf
Health Benefit Plan Claim Form (español)
- Si cuenta con cobertura del Plan de Beneficios de Salud y ha pagado servicios médicos de su propio bolsillo, debe completar este formulario y enviarlo a IMG junto con una factura detallada y/o los recibos de pago. También puede enviarlo en línea a través de su cuenta de IMG AmeriCorps VISTA.
|
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
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
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
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. This form can be submitted online using your IMG AmeriCorps VISTA account.
|
Download
|
|
pdf
Injury and Accident Form (español)
- Si recibió atención médica debido a una lesión o accidente, deberá enviar este formulario a IMG para que podamos tramitar las reclamaciones correspondientes. Puede enviar este formulario en línea a través de su cuenta de IMG AmeriCorps VISTA.
|
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. This can be submitted online using your IMG AmeriCorps VISTA account.
|
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. This can be submitted online using your IMG AmeriCorps VISTA account.
|
Download
|
|
pdf
Prescription Direct Mail Enrollment Form
- This form can be used to have your prescription medications & refills delivered directly to your home. NOTE: For your convenience, we recommend enrolling online at https://www.envisionpharmacies.com/mail or calling to 866-909-5170.
|
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
|
|
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
|
