Members can also access forms directly by signing in to MyGreatWest.com.
Claim Forms
Medical Claim Form (PDF, 27KB)
Notice of Continuing Claim Form (PDF, 20KB)
Short version used after submitting your first claim in a calendar year
Prescription Drug Claim Form (PDF, 239KB)
Dental Claim Form (PDF, 18KB)
Vision Claim Form (PDF, 24KB)
Short Term Disability Claim Form (PDF, 35KB)
Flexible Spending Account Forms
Flexible Spending Account Enrollment Form (PDF, 114KB)
Flexible Spending Account Reimbursement Request (PDF, 106KB)
Flexible Spending Account Status Change Form (PDF, 104KB)
Life Claim Reports
Life Claim Report: California-Sitused Employers (PDF, 36KB)
Life Claim Report: Non-California Employers (PDF, 31 KB)
Medicare Part D
Model Creditable Coverage Disclosure Notice (for use after May 2006) (MS Word, 52KB)
Model Non-Creditable Coverage Disclosure Notice (for use after May 2006) (MS Word, 82KB)
Creditable coverage notice – CMS guidance (1/06) (PDF, 53KB)
Transition of Care
Transition of Care Benefits (PDF, 139KB)
Continuity of Care Request for California HMO (PDF, 33KB)
Other Notices