Individual Forms
Cox HealthPlans has provided the following forms to assist you in the administration of your client’s group health plan.
Agent Field Guide - This is used to provide brokers with information regarding our indivdual products.
Authorization for Release of Health Info - This form is used to designate those people allowed to receive information about your policy.
Coordination of Benefits - This form is used to verify if you or your enrolled dependents have other insurance coverage while insured with Cox HealthPlans.
Direct Payment - This form is used for premium payments to be automatically deducted from your bank account.
First Health Information/Service Area Map - This provides information regarding the Cox HealthPlans Service area, and access to First Health for nationwide PPO coverage.
Individual Application - This form is used to apply for individual health coverage.
Individual Policy Change Form - This form is used to request changes to an existing individual policy.
Medical Claim - This form is used if a member needs to submit a medical claim.
Prescription Claim - This form is used if a member needs to submit a prescription claim.
Prescription Mail Order - This is the form used to request mail order service for prescription medications.
Prescription Prior Authorization - This form is used by a physician to request authorization of a particular prescription medication.
PrimeStar Classic Dental Claim Form - This form is used if a member needs to submit a dental claim who has coverage with Security Life.
Security Life Dental and Vision - This form is used to enroll in individual dental and vision insurance through our partner Security Life.
Self Referal - Case Managment - This form is used to request assistance from our Medical Management Team.
If you have any questions or concerns, or need additional assistance, please contact the Cox HealthPlans Marketing Department at:
Phone 417.269.4679 or 800.664.1244 Fax 417.269.4667 E-mail grouphealth@coxhealthplans.com
Mailing Address
Cox HealthPlans
PO Box 5750
Springfield, MO 65801-5750
Or visit us at
Cox HealthPlans
Kelly Plaza
3200 S. National, Building B
Springfield, MO 65807