Insurance Policy & Claim Forms:

On every Midwest claim submission, a Midwest Claim Form should be filled out completely and submitted with the physician and/or hospital bill.

On every Midwest dental claim submission, a Midwest Dental Claim Form should be filled out completely with a Dentist bill.

Have more than one insurance policy? Complete this form and submit it with your claims to save on processing time.

This form is used to confirm the direction of an individual that our Company use or disclose protected health information for a particular purpose. Subsequent requests will require new authorization.

If your claim is due to an accident, please complete this form and submit it with your claim to save processing time.

This form may be used to request a review of a recent decision.

Use this form to submit requests for changes on your coverage.

Use this form to submit requests for others to make inquiries upon your behalf.