Forms library

Downloadable and printable FCHP forms for all your needs.

It Fits! reimbursement form
Complete this form to receive reimbursement for health club memberships, school sports league fees, and more.

Prescription mail-order form
Use this form to fill prescriptions with our mail-order pharmacy. (This form can't be used by our MassHealth or Medicare plan members. Call FCHP's Customer Service Department for more information.)

Claim form for our Fallon Preferred Care (PPO) plans
Use this form to request repayment of a performed medical service.

Verification of dependent status form
Use this form to confirm the status of any dependents covered under your health plan.

ASO student recertification form
Use this form to confirm the status of any full-time students covered under your health plan (ASO plans only).

HIPAA forms

• Amendment Request for Personal Information form
  Request changes to your record if you think it is inaccurate or incomplete. This form is not required for corrections to your address, date of birth or name.
  
• Authorization for Release of Personal Information form
  Allow another individual/entity to receive your personal information from FCHP (such as your employer, if they are working on your behalf to resolve a claim issue).
  
• Veteran’s Office Authorization for Release of Personal Information form
  Allow a veteran’s office to receive your personal information from FCHP.
  
• Personal Representative Authorization form
  Identify a personal representative—someone FCHP can release your personal information to. Complete a form for each person you want to have as a representative.
  
• Request for an Accounting of Disclosures of Personal Information form
  Request a listing of who FCHP has shared your information with (after April 14, 2003) for reasons other than treatment, payment or health care operations.
  
• Restriction form
  Request a limit on how we use or share your personal information.