MESSA MEMBER FORMS
As a service to our members, we have made many of our most frequently requested forms available here for easy download.
These forms are in Adobe portable document format (PDF). In order to view and print these documents, you will need to have Adobe Acrobat Reader installed on your computer. Log in to MyMESSA® for access to all member forms and specific information about your coverage including, deductible progress, benefits, claims and account management.
A standardized Health Insurance Claim Form can be completed and mailed with provider receipt(s) for benefit reimbursements.
This form should be completed by the member and mailed with provider receipt(s) for benefit reimbursements.
This form should be completed by the member when costs are incurred during international travel, and mailed to MESSA with provider receipt(s) for benefit reimbursements.
This form should be completed by the member and mailed with the prescription to OptumRx for home delivery.
This form should be completed by the member and their health care provider, and faxed to OptumRx from the prescribing provider’s office on Dec. 14, 2021, or later.
This completed form should be submitted and approved prior to services being rendered at a non-PPO physician, hospital, or laboratory. The highlighted fields on the form are required in order to process the referral.
This form should be completed by the member and mailed or faxed to Express Scripts for prescription claim reimbursement.
- Accident Claim Form for MESSA supplemental plan
- Hospital Claim Form for MESSA supplemental plan
- Critical Illness Claim Form for MESSA supplemental plan
This form must be completed by your employer when you apply for STD or LTD income benefits.
This form must be completed to apply for STD or LTD income benefits.
This form must be completed by your disabling provider when applying for disability benefits.
This form must be completed to authorize electronic fund transfer for disability benefits.
OptionALL Medical / Dependent Care Flexible Spending Account
OptionALL Medical Reimbursement Flexible Spending Account (FSA) Withdrawal Request
OptionALL Dependent Care Spending Account Plan Withdrawal Request
OptionALL Health Savings Account (HSA) Contribution Program
Premium Contribution or Cash in Lieu Election and Authorization
This notice describes how medical information about you may be used and disclosed by entities covered under the HIPAA privacy rules.
Members should use this form to provide MESSA with written authorization to use, discuss or disclose their PHI with a third party.
Similar to the written authorization form, this form is required for specific authorization to use or disclose psychotherapy notes to MESSA or from MESSA.
Members should use this form to request a summary of disclosures (with a six year maximum) by MESSA of their PHI.
This form is for members to request an amendment to the PHI MESSA maintains.
This form is for members to request a review of the records MESSA maintains containing their PHI.
Members may request that MESSA further restrict the disclosure of their PHI beyond what is authorized by the HIPAA law, but MESSA is not compelled to agree. This form is used to submit the request to MESSA.
A form for members or dependents to use to request alternative confidential communication.
This form is for members to revoke a previously submitted authorization form.
Members can use this form to submit a complaint or request an investigation about a suspected HIPAA (PHI) disclosure.
Women’s Health and Cancer Rights Act
Newborns’ and Mothers’ Health Protection Act
Nonopioid Directive Form – This form can be found here: https://www.michigan.gov/opioids/find-help
As a service to our members, we have made many of our most frequently requested forms (member claim Forms, disability claim forms, beneficiary designation forms, enrollment forms, optionAll forms, privacy forms) available here for easy download.