Forms library

Tax forms
Learn more about the 1095 and 1099-HC forms you need for your tax filings. 

It Fits! reimbursement form  
Complete this form to receive reimbursement for health club memberships, school sports league fees, and more.

Prescription mail-order form  
Use this form to fill prescriptions with our mail-order pharmacy. (This form can't be used by our MassHealth or Medicare plan members. Call Fallon's Customer Service Department for more information.)

Medical claim form (Request for Payment of Medical Services)  
Use this form to request repayment of a performed medical service.

Pharmacy claim form (Request for Payment of Pharmacy Services)
Use this form to request repayment of pharmacy services.

You can also submit a reimbursement claim online on the CVS Caremark website. Just log in, go to "Plan & Benefits," and choose "Submit Prescription Claim."


HIPAA forms

For our commercial members

Amendment Request for Personal Information form
This form is used to ask us to make changes to your record if you think it is inaccurate or incomplete. You do not need to use this form for corrections to your address, date of birth or name.

Authorization for Release of Personal Information form
This form authorizes Fallon Health to give your personal information to another individual or entity (such as your employer, if they are working on your behalf to resolve a claim issue).

Personal Representative Authorization form 
This form is for Fallon Health members to give permission to Fallon to disclose your personal information to a designated person and/or to give permission to someone else to file an appeal on your behalf.

For our MassHealth members

Personal Representative Authorization Form
This form is for Fallon MassHealth members to give permission to Fallon to disclose your personal information to a designated person and/or to give permission to someone else to file an appeal on your behalf.

For all members (as appropriate)

Authorization for Release of Premium Billing Information to Veterans Administration (VA)
Use this form to request and authorize Fallon Health to release your monthly premium bill to a VA office for payment.

Request for an Accounting of Disclosures of Personal Information form
This form is used to request a listing of who Fallon Health has shared your information with for reasons other than treatment, payment or health care operations. Please note there are limitations to the number of prior years you may request.

Restriction form
This form is used to put limitations on how we use or share your personal information.

For our Fallon Senior Plan and NaviCare members

For Fallon Senior Plan and NaviCare members, please visit the forms page for Fallon Senior Plan and the forms page for NaviCare.