Member Forms

Title
pdf Coverage Information Form - In order for IMG to accurately process your medical claims and ensure that you receive the maximum benefits available, you must complete this form at the beginning of each service term and/or whenever there is a change in your other coverage status. Please note: You may also submit your information online via your MyIMGNCCC account. Download
pdf Coverage Information Form (español) - A fin de que IMG pueda procesar correctamente sus reclamos y garantizar que usted reciba los máximos beneficios disponibles, este formulario se debe proporcionar a IMG al comienzo de cada nuevo período de servicio y/o cuando haya cambios en su estado de cobertura de gastos médicos. Nota: También puede acudir a su cuenta en línea de MyIMGNCCC para proporcionar esta información. Download
pdf Health Benefit Plan Claim Form - If you are covered under the Health Benefit Plan and you have paid for medical services out-of-pocket, this form must be completed and returned to IMG along with a detailed bill and/or payment receipts. Download
pdf Health Benefit Plan Claim Form (español) - Si usted pagó por servicios médicos de su bolsillo, debe proporcionar este formulario a IMG junto con la(s) factura(s) detallada(s) del proveedor, recibos de pago y la Explicación de Beneficios (EOB) de otros seguros (si corresponde). Download
pdf Injury and Accident Form - If medical treatment was sought due to an injury or accident, you will need to submit this form to IMG in order for us to process the related claims. Download
pdf Injury and Accident Form (español) - Si usted recibió tratamiento médico debido a un accidente o una lesión, tendrá que proporcionar este formulario a IMG con el fin de que podamos procesar los reclamos relacionados. Download
pdf ACH Wire Transfer Form - If you wish to have any reimbursements payable to you to be directly deposited into your account, you may fill out this form, and the information will be securely kept on file. If you need to make a change, simply submit a new form. Download
pdf ACH Wire Transfer Form (español) - Si desea que IMG use Depósito Directo para enviar un reembolso por reclamos médicos u otros gastos médicos reembolsables que usted pago como miembro, debe proporcionar este formulario a IMG y la información será mantenido en un archivo protegido. Si necesita hacer un cambio, sólo tiene que proporcionar un nuevo formulario. Download
pdf Privacy Confidentiality Release Form - In order for IMG to discuss your claims activity with anyone other than you and your physician(s) or provider(s) of service, for example a parent or spouse, you must complete this form and submit it to us. Download
pdf Privacy Confidentiality Release Form (español) - A fin de que IMG pueda compartir sus actividades de reclamos con alguien que no sea médico o proveedor de servicios médicos, por ejemplo, un padre o cónyuge, debe proporcionar este formulario a IMG. Download
pdf Prescription Direct Mail Form - This form can be used to have your prescription medication refills delivered directly to your home. You may also submit this request online at https://shopping.drugsourceinc.com/Default.asp or by downloading the DrugSource mobile app at https://shopping.drugsourceinc.com/mobile/rx/. Download
pdf Subrogation Agreement - If you are covered under the Health Benefit Plan and a third-party is considered the cause of or is at-fault for your accident, injury, etc., then this form must be completed, signed and submitted to IMG. Download
pdf Subrogation Agreement (español) - Si un tercero se considera la causa o el culpable de su accidente, lesiones, etc., debe proporcionar este formulario a IMG. Download
pdf Domestic Volunteer Service Act AmeriCorps Secondary Not Insurance - The health benefit provided by AmeriCorps to its volunteer members is secondary to all commercial insurance, including when the AmeriCorps Member is listed as a dependent on a commercial product. Download
pdf AmeriCorps NCCC Health Benefit Plan Guide - This guide provides an overview of the AmeriCorps Health Benefit Plan as well as how to use your benefits for covered medical expenses. Download
pdf AmeriCorps NCCC Health Benefit Plan Guide (español) - Esta guía proporciona una visión general del Plan de Beneficios de Salud de AmeriCorps y como usar sus beneficios para los gastos médicos que están cubiertos. Download