Forms & Resources

Use these resources to better manage your plan. We now offer form submission via DocuSign on many items, to help you save time and streamline the submission process. If you have questions or need additional guidance or information, contact your agent.

General Resources

Appeal Request Form

Use this form to submit an appeal on a claim. Make sure you have you have a copy of the claim or the Explanation of Benefits (EOB) to include with your submission.

Request for Appointment of Personal Representative Form

Plan Members must complete this information to release PHI to a provider or other party.

SafeGuard Preventative Services

Rights and Protection

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

Machine Readable Files

In order to comply with the Transparency in Coverage legislation, insurance plans are required to make available machine-readable files for in-network rates (for providers in the plan’s network) and for out of network rates (for providers not in the plan’s network). Select the desired file for more information. Please note: These files contain a large amount of data and may require several minutes to download/open.

In-Network MRF



Out-of-Network MRF




Questions? Contact Us.

We’re here to answer your questions or get your the information you need. Contact us using the customer service number found on your ID card.

Learn more about the plans Ascension Personalized Care (APC) offers. APC is Individual ACA Marketplace coverage.
To find your general agent, click here: