• Transition of Care Form
  • Transition of Care Form - English (PDF)
  • Transition of Care Form -  Spanish (PDF) 
    
    
• PHI Authorization Form (PDF)
  • Use this form when you want to allow Ascension Complete to share your health information with a person or group.

•  PHI Revocation Form (PDF)
  • Use this form when you want Ascension Complete to cancel or revoke your previous permission to share health information with a person or group.

• Appointing a Representative (PDF)
  • Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.

• Multi-language Interpreter Services (PDF)
  • We have free interpreters to answer questions in multiple languages. Call Member Services.

• Disenrollment Form
  • Disenrollment Form - English (PDF)
  • Disenrollment Form - Spanish (PDF)
  • We don't want to see you go. Let us improve your experience with our plan. Please call Member Services. We are here to help. If you are still dissatisfied, please fill out and mail the disenrollment form.
• Scope of Appointment
  • Scope of Appointment Form - English (PDF)
  • Scope of Appointment Form - Spanish (PDF)
• Member Reimbursement Claim Forms
  • Member Reimbursement Claim Form - English (PDF)
  • Member Reimbursement Claim Form - Spanish (PDF)

• Transition of Care Form
  • Transition of Care Form - English (PDF)
  • Transition of Care Form - Spanish (PDF)
    
    
• PHI Authorization Form (PDF)
  • Use this form when you want to allow Ascension Complete to share your health information with a person or group.

• PHI Revocation Form (PDF)
  • Use this form when you want Ascension Complete to cancel or revoke your previous permission to share health information with a person or group.

• Appointing a Representative
  • Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.

• Multi-language Interpreter Services (PDF)
  • We have free interpreters to answer questions in multiple languages. Call Member Services.

• Disenrollment Form - We don't want to see you go. Let us improve your experience with our plan. Please call Member Services. We are here to help. If you are still dissatisfied, please fill out and mail the disenrollment form.
  • Disenrollment Form - English (PDF)
  • Disenrollment Form - Spanish (PDF)

• Scope of Appointment Form
  • Scope of Appointment Form - English (PDF)
  • Scope of Appointment Form - Spanish (PDF)

• Member Reimbursement Claim Form
  • Member Reimbursement Claim Form - English (PDF)
  • Member Reimbursement Claim Form - Spanish (PDF)

• Transition of Care Form (PDF)
• PHI Authorization Form (PDF)
  • Use this form when you want to allow Ascension Complete to share your health information with a person or group.

• PHI Authorization Form (PDF)
  • Use this form when you want to allow Ascension Complete to share your health information with a person or group.
     
• PHI Revocation Form (PDF)
  • Use this form when you want Ascension Complete to cancel or revoke your previous permission to share health information with a person or group.

• Appointing a Representative
  • Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.

• Multi-language Interpreter Services (PDF)
  • We have free interpreters to answer questions in multiple languages. Call Member Services.

• Disenrollment Form (PDF)
  • We don't want to see you go. Let us improve your experience with our plan. Please call Member Services. We are here to help. If you are still dissatisfied, please fill out and mail the disenrollment form.
    

• Scope of Appointment Form
  • Scope of Appointment Form - English (PDF)
  • Scope of Appointment Form - Spanish (PDF)

• Member Reimbursement Claim Form
  • Member Reimbursement Claim Form - English (PDF)
  • Member Reimbursement Claim Form - Spanish (PDF)

• Transition of Care Form
  • Transition of Care Form - English (PDF)
  • Transition of Care Form -  Spanish (PDF) 
    
    
• PHI Authorization Form (PDF)
  • Use this form when you want to allow Ascension Complete to share your health information with a person or group.

•  PHI Revocation Form (PDF)
  • Use this form when you want Ascension Complete to cancel or revoke your previous permission to share health information with a person or group.

• Appointing a Representative (PDF)
  • Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.

• Multi-language Interpreter Services (PDF)
  • We have free interpreters to answer questions in multiple languages. Call Member Services.

• Scope of Appointment
  • Scope of Appointment Form - English (PDF)
  • Scope of Appointment Form - Spanish (PDF)
• Member Reimbursement Claim Forms
  • Member Reimbursement Claim Form - English (PDF)
  • Member Reimbursement Claim Form - Spanish (PDF)

• Transition of Care Form
  • Transition of Care Form - English (PDF)
  • Transition of Care Form - Spanish (PDF)
    
    
• PHI Authorization Form (PDF)
  • Use this form when you want to allow Ascension Complete to share your health information with a person or group.

• PHI Revocation Form (PDF)
  • Use this form when you want Ascension Complete to cancel or revoke your previous permission to share health information with a person or group.

• Appointing a Representative
  • Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.

• Multi-language Interpreter Services (PDF)
  • We have free interpreters to answer questions in multiple languages. Call Member Services.

• Scope of Appointment Form
  • Scope of Appointment Form - English (PDF)
  • Scope of Appointment Form - Spanish (PDF)

• Member Reimbursement Claim Form
  • Member Reimbursement Claim Form - English (PDF)
  • Member Reimbursement Claim Form - Spanish (PDF)

• Transition of Care Form (PDF)
• PHI Authorization Form (PDF)
  • Use this form when you want to allow Ascension Complete to share your health information with a person or group.

• PHI Revocation Form (PDF)
  • Use this form when you want Ascension Complete to cancel or revoke your previous permission to share health information with a person or group.

• Appointing a Representative
  • Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.

• Multi-language Interpreter Services (PDF)
  • We have free interpreters to answer questions in multiple languages. Call Member Services.

• Scope of Appointment Form
  • Scope of Appointment Form - English (PDF)
  • Scope of Appointment Form - Spanish (PDF)

• Member Reimbursement Claim Form
  • Member Reimbursement Claim Form - English (PDF)
  • Member Reimbursement Claim Form - Spanish (PDF)

• Transition of Care Form (PDF)

• Member Reimbursement Claim Form - English (PDF)
• Member Reimbursement Claim Form - Spanish (PDF)

Scope of Appointment

• Scope of Appointment Form - English (PDF)
• Scope of Appointment Form - Spanish (PDF)

• Use this form when you want to allow Ascension Complete to share your health information with a person or group.

PHI Revocation Form (PDF)

• Use this form when you want Ascension Complete to cancel or revoke your previous permission to share health information with a person or group

Appointing a Representative (PDF)

• Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.

• Transition of Care Form (PDF)

• Member Reimbursement Claim Form - English (PDF)
• Member Reimbursement Claim Form - Spanish (PDF)

Scope of Appointment

• Scope of Appointment Form - English (PDF)
• Scope of Appointment Form - Spanish (PDF)

Multi-language Interpreter Services (PDF) - We have free interpreters to answer questions in multiple languages. Call Member Services.

PHI Authorization Form (PDF)

• Use this form when you want to allow Ascension Complete to share your health information with a person or group.

PHI Revocation Form (PDF)

• Use this form when you want Ascension Complete to cancel or revoke your previous permission to share health information with a person or group.

Appointing a Representative (PDF)

• Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.

• Transition of Care Form (PDF)
• Member Reimbursement Claim Form - English (PDF)
  Member Reimbursement Claim Form - Spanish (PDF)

Scope of Appointment

• Scope of Appointment Form - English (PDF)
• Scope of Appointment Form - Spanish (PDF)

Multi-language Interpreter Services (PDF) - We have free interpreters to answer questions in multiple languages. Call Member Services.

PHI Authorization Form (PDF)

• Use this form when you want to allow Ascension Complete to share your health information with a person or group.

PHI Revocation Form (PDF)

• Use this form when you want Ascension Complete to cancel or revoke your previous permission to share health information with a person or group.

Appointing a Representative (PDF)

• Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.

• Member Reimbursement Claim Form - English (PDF)
• Member Reimbursement Claim Form - Spanish (PDF)

Scope of Appointment

• Scope of Appointment Form - English (PDF)
• Scope of Appointment Form - Spanish (PDF)

Multi-language Interpreter Services (PDF) - We have free interpreters to answer questions in multiple languages. Call Member Services

• Transition of Care (PDF)

PHI Authorization Form (PDF)

• Use this form when you want to allow Ascension Complete to share your health information with a person or group.

PHI Revocation Form (PDF)

• Use this form when you want Ascension Complete to cancel or revoke your previous permission to share health information with a person or group.

Appointing a Representative (PDF)

• Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.

• Member Portal (PDF)
• Lower Out of Pocket Costs (PDF)