Our forms and notices are available online as Adobe AcrobatTM (PDF) forms. To view and print these forms and notices, you will need the free Acrobat Reader, which you can download here.

You may either complete the forms on your computer and print them out completed, or print the blank form and fill it out by hand.

Claim Form

English pdf

Download this form before you see your provider.

Grievance Form

English pdf   Spanish (Español) pdf

Download this form to submit a complaint to MES.

Patient Grievance Procedures

English pdf   Spanish (Español) pdf

This document describes MES' grievance procedures if you are considering to initiate a grievance.

HIPAA Notice of Privacy Practices

English pdf   Spanish (Español) pdf

This document describes your privacy rights with MES. Please print this document and save it in your records.

HIPAA - Patient Authorization Form

English pdf   Spanish (Español) pdf

This form authorizes MES to release your medical information to the providers you specify.

Independent Medical Review Form

English pdf   Spanish (Español) pdf

Download this form to request a Independent Medical Review (IMR) from the DMHC.

Non-Elective(Medically Necessary) Contact Lenses Approval Form

English pdf

Download this form and give it to your doctor to get approval for contacts.

Notice of Availability of Language Assistance Services

Important Information Regarding Available Language Assistance Services pdf

Informacion Importante Sobre Los Servicios Disponibles De Asistencia En Idiomas  pdf

Notice of Availability of Language Assistance Services (DMHC) pdf

Notice of Availability of Language Assistance Services (DOI) pdf

The notice discloses the availability of language assistance services and explains how to access those services. The notice is translated into multiple languages.

Patient Feedback Form

English pdf   Spanish (Español) pdf

Download this form to submit your feedback, comments, and questions to MES about the services you received.

Patient Feedback Form (Language Assistance Services)

English pdf   Spanish (Español) pdf

Download this form to submit your feedback, comments, and questions to MES about the language assistance services (verbal interpretation and/or written translation) you received.