Forms & Documents

Use the tabs below to find the right forms for you. If you can’t find what you’re looking for, check the Contact Us page and give us a call!

Guardian Members

Guardian PPO and DHMO Complaint Form — IL
Guardian PPO ADA Claim Form

Member Grievance Forms
Guardian PPO and DHMO Grievance Form — FL and NY
Guardian PPO and DHMO Grievance Form — TX
Guardian PPO and DHMO Grievance Form — All other states

Dependent Eligibility Certification Forms
Dependent Eligibility Certification Form – CO and FL
Dependent Eligibility Certification Form – CT
Dependent Eligibility Certification Form – IL
Dependent Eligibility Certification Form – MN
Dependent Eligibility Certification Form – NY
Dependent Eligibility Certification Form – OH
Dependent Eligibility Certification Form – PA
Dependent Eligibility Certification Form – Student Certification
Dependent Eligibility Certification Form – Student & Dependent Certification

Premier/Access Members

Dentist Nomination Form
Dental Claim Form
HIPAA Authorization (English)
HIPAA Authorization (Spanish)
Notice of Privacy Practices (English)
Notice of Privacy Practices (Spanish)
Language Assistance Services
AZ Appeal Packet

Member Grievance Forms
Premier Grievance Form — PPO
Premier Grievance Form — DHMO (English)
Premier Grievance Form — DHMO (Spanish)
Premier Grievance Form — DHMO (Chinese)

Privacy Policies and Forms
Click here to view and download a complete list of Guardian privacy policies and forms.

Note: To use these forms you need Adobe Acrobat Reader installed on your computer.Get Acrobat Reader now »

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