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Member Forms

Behavioral Health and Physical Health Doctors Working Together

Behavioral/Physical Health Coordination Form (PDF)
It’s important for both your behavioral and physical healthcare providers to know what kind of care you are getting. Keep your doctors connected by taking the Behavioral/Physical Health Coordination form to your next visit.

Get Access to your Personal Health Information

Authorization of the Use and Disclosure of Protected Health Information (PDF)
Completing this form will allow MHS to share your personal health information with another company or individual that you name.

Choose a Representative to Appeal

Authorization for Another Person to Appeal in your Name (PDF)
Completing this form will allow a person that you choose represent you in an appeal for services from MHS.

Contact the State to Report a Change (Address, Phone Number, etc.)

Call the Department of Family Resources (DFR) at 1-800-403-0864 or go to the FSSA Benefits Portal

If you would like this information in print, please contact MHS Member Services.

Last Updated: 09/08/2022