Everything You Need for Your Health Coverages

Manage your AultCare account with a full complement of member forms — for claims, HIPAA guides, other coverages, other AultCare departments, and more.

Account Login

Claim Forms

Accident Questionnaire — Provide additional information regarding accident or injury.
Accident Questionnaire - Spanish — Cuestionario de Accidentes Proporcione información adicional sobre accidentes o lesiones.
Dental Claim Form — Form & instructions for filing a Dental Claim.
Flexible Spending Claim Form (Medical) — Instructions and form to submit healthcare spending account claim for reimbursement of medical expenses.
Dependent Care Flexible Spending Claim Form
EFT Form - Marketplace Members can pay their monthly premium using their bank account.
Request a Member Card Replacement - Use this guide to log into your member portal to request a new ID card
Medical/Rx Claim Form — Form & instructions for filing a Medical/Rx Claim.
Vision Claim Form — Form & instructions for filing a Vision Claim.

Guides & Directives

Advanced Directives — The Ohio Hospital Association offers an online packet of the Advance Directives Forms.
Member Guide - Resource to learn more about your health plan.
Multi-language Interpreter Services/Non-discrimination Notice — Multi-language Interpreter Services/Non-discrimination Notice.
Referral and Prior Authorization Guidelines — Instructions regarding pre-certification (p re-approval/pre-authorization ).
Sample Explanation of Benefits — Consolidated Explanation of Benefits sample with instructions on how to read your CEOB.
Surprise Billing Model Notice - Explanation of your rights and protections against surprise medical bills

HIPAA Forms

HIPAA Access Request Form — Members can use this form to access their insurance Protected Health Information (PHI) from AultCare. Please route this request to the Privacy Coordinator at AultCare. Please allow a 15-day turnaround response time for this request.
HIPAA Amendment Request Form — Members can use this form to request a change to the Protected Health Information (PHI) AultCare has on file. This can be used if the member has found an error in their PHI.
HIPAA Confidential Communication Request Form — Members can use this form to request their Explanation of Benefits (EOB) or other AultCare communications are confidentially sent to a different address than what is on file, or phone calls are made to a different phone number. If you feel harm may be caused if your information is sent to anyone outside of you, please complete the Member Request to Restrict Uses and Disclosures Form.
HIPPA Designation of Authorized Representative Form — Members can use this form to designate someone other than you to speak to us on your behalf. Legal documentation (such as a General or Durable Power of Attorney or Guardianship) is required to allow an Authorized Representative to make actual changes on your behalf.
HIPAA Member Restrict Uses and Disclosures — Members can use this form to limit who has access to their Protected Health Information (PHI).

Other Coverage Forms

Continuation Of Coverage Form — For a child who is incapable of self-sustaining employment by reason of mental or physical disability and who has reached the limiting age for dependent children specified in the plan or contract. Or for the continuation of dependent coverage for college students (FTS) who would otherwise lose eligibility because of a reduction in their full-time class status or a medically necessary leave of absence from the school itself.
Flexible Spending Claim Form (Dependent) — Instructions and form to submit Dependent Care Account claim for reimbursement of dependent care expenses.
Full-Time Student/ Dependent Verification Form — AultCare verifies dependent information annually to ensure that claims are processed according to your plan's guidelines. Notification required within 30 days if dependent's full-time status changes dependent does not meet Health Plan guidelines.
Other Coverage Information Form — Printable form for other coverage information.
Other Coverage Information Form - Spanish - Printable only
Other Coverage InformationForm- Spanish — e-Fillable / Printable form for other coverage information.
Other Coverage Information Form (electronic) — Electronic version of the "Other Coverage Information Form."
Other Coverage Information Form (including Timken) — Printable form for other coverage information.
Preventive Care, Benefits, and Services — Printable flyer listing suggested preventive care guidelines to discuss with your Primary Care Physician (PCP).

Other AultCare Departments

Pharmacy Forms
AultCare Authorization for Direct Deposit for Short Term Disability — Authorizing AultCare to deposit pay automatically to the account indicated.
Fraud, Waste, and Abuse
Surprise Billing Notice

Appeals & External Review

Internal Appeal Request Form — If you disagree with a determination decision about a specific benefit, you have the right to file an internal appeal with AultCare using this form. You may also submit your appeal in writing and include any written comments, documentation, or records relevant to your appeal.
AultCare Treating Physician Certification for Experimental or Investigational ABD — You may have your provider complete this form if your request for benefit determination has been denied as Experimental or Investigational. (We do not require the completion of this form, but provide it for your convenience. Your provider must certify to us in writing that your request is of an expedited nature before we will proceed with it as an expedited appeal.)
AultCare Treating Physician Certification for Internal Appeal and/or External Review — You may have your provider complete this form if your request for benefit determination has been denied and you are requesting an expedited appeal or review. (We do not require the completion of this form, but provide it for your convenience. Your provider must certify to us in writing that your request is of an expedited nature before we will proceed with it as an expedited appeal.)
External Review Request Form — If you disagree with our appeal decision and have exhausted your internal appeal rights, you can request an External Review using this form. (For Insured and Public Employer Plans only.)
AultCare Request for Review by the Ohio Department of Insurance — If we have denied your request for an External Review and you disagree with our decision, please use this form.
External Review Procedures Summary — An explanation of the External Review procedure for all Insured and Public Employer Plans effective 02/2012.

Contact Info

Have a Question?

AultCare Customer Service Hours: 7:30 am to 5:00 pm EST.

Additional Information

Pharmacy Services

Pharmacy Services

Care Coordination

Transparency in Coverage
Hospital & Physician Information Validation

Provider Information

Member Information

AultCare Mobile App

Download access to your Member Portal through either app store.