Printer-Friendly Forms

Prescription Drug Claim Form – To file prescription drug claims, complete this form and attach your prescription receipt or a print-out of your prescriptions signed by your pharmacist.

Bank Draft Authorization Form – If you need to change your bank information for your monthly premium payment, complete this form, attach a voided check and mail both to TRH.

Certification of Dependency – Complete this form and mail it to TRH to verify your dependent’s eligibility. It is important to verify that your dependents between the ages of 18 and 23 continue to be eligible on your coverage. You should notify TRH immediately of any change of status for your dependents.

Other Insurance Form – You should always keep TRH informed of other insurance that you and your dependents may have as TRH coverage contains a coordination of benefits provision. Complete this form and mail it to TRH when you obtain other insurance.

Personal Representative Form – Your completion of this form allows you to designate someone as your personal representative on your TRH health care coverage.

For more information regarding TRH’s privacy practices click here for a copy of the Notice of Privacy Practices.