Forms

Forms
ClaimLinx specializes in the benefit administration of self-funded medical expense reimbursement plans (MERP). Specifically, ClaimLinx administers Section 105 health plans that combine a high deductible health plan with employers self-funding a portion of the benefit plans. ClaimLinx can assist in consulting services as well as the design of the benefit plan, process claims, educate members and pay providers.

Below are some frequently used forms provided as a convenience to our members, employers, consultants/brokers and providers.

All forms are formatted in Adobe Acrobat Reader. If you do not have Adobe Acrobat Read - Download Adobe for free here.

· Member Packet:
(Refer to your ID card letter for the correct packet.)
- Member Packet with RX Reimbursement
- Member Packet with no RX Reimbursement

· Prescription:
- Prescription Expense Reimbursement Form and Instructions
- PBM Plus Reimbursement Claim Form
- HealthSmart RX Reimbursement Claim Form

· Medical:
Medical/Dental Expense Reimbursement Form

· Vision:
Vision Expense Reimbursement Form

· General Administration:
- ID Card Request Form
- Change of Address Form (Providers & Members)
- MERP Client Processing Change Request Form
- MERP Termination Form

· Brochures
Why you Should Choose ClaimLinx

Eliminate the hassle of administering a self-funded benefit plan by contacting us. Our experienced staff is eager to coordinate a benefit plan that is right for you!

10260 Alliance Road
Suite 130
Cincinnati, OH 45242
(513) 677-6262 or (800) 858-1772 phone
(513) 677-6263 or (800) 858-1913 fax

Health Care Consulting & Benefit Administration

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