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
Download this form to submit a complaint to MES.
Patient Grievance Procedures
This document describes MES' grievance procedures if you are considering to initiate a grievance.
HIPAA Notice of Privacy Practices
This document describes your privacy rights with MES. Please print this document and save it in your records.
HIPAA - Patient Authorization Form
This form authorizes MES to release your medical information to the providers you specify.
Independent Medical Review Form
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
Notice of Availability (DMHC) pdf Notice of Availability (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.
