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These forms apply to EquiCare 2002 and 2020 policies. Before using these forms please contact the Specialty Unit to inquire about eligibility for benefits.
Use this form for your initial assessment or as a resource for your assessment form to see if you would need to add any additional information to your current form.
Use this form for caregiver documentation or as a resource for the caregiver note your use to see if you would need to add any additional information to your current form. *Please note how level and frequency of care provided is documented.
The following forms require prior approval for benefits. If the elibigility requirements have not been met please contact our Intake Unit at 1-800-352-5150 ext. 3315.
Use this to file a claim for any of the policy form #'s listed below:
General Forms
Pay Provider Direct