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 and mailed with the Rx order form to Express Scripts for home delivery pharmacy service.

This form should be used when you are being referred for services to a non-PPO physician, hospital or laboratory.

This form should be completed by your physician and mailed to the MESSA Member Services Department for authorization prior to services being performed.

This form should be used to apply for transitional care for ongoing treatment with a non-network provider.

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 physician or psychologist when applying for mental health disability benefits.

This form must be completed to apply for LTD income benefits.

This form must be completed to authorize electronic fund transfer for disability benefits.

This form should be completed by the member to change beneficiary designation for MESSA life insurance. Complete the Non-Negotiated Life Insurance section of the form if you have Basic Term Life or Supplemental Term Life. Complete the Negotiated Life Insurance section if you have PAK Life or Negotiated Life insurance. If you have both Non-Negotiated and Negotiated Life Insurance, please complete both sections of the form. Please fill out completely, sign and return to MESSA Group Services.

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.

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.