Forms

To facilitate member claims, please note the following guidelines:

1. Fill out all fields required and check boxes as appropriate.
2. All items should be marked legibly using ballpen or sign pen only.
3. Write your complete name. Extensions such as, but not limited to, "Jr.", "Sr.", or "III" should be properly indicated.
4. Forms should be accomplished and submitted together with complete attachments/requirements listed per claim form.

Should you have questions, please contact the CoopHealth Claims Department at 0917-3189622 or This email address is being protected from spambots. You need JavaScript enabled to view it..

1. Reimbursement Request Form - for availments to non-accredited providers
2. HIB Reimbursement Form - reimbursement for members enrolled in Hospital Income Benefit
3. Death Benefit Claim Forms - includes the following forms:
   1. Death Benefit Claim Form - in case of death of member
   2. Physician's Statement - if member died in the hospital
   3. Claimant's Statement Form - if deseased member was single
4. ID Replacement Form - for replacement of CoopHealth ID Card