Enrollee Forms
Transportation
- HSCSN Family Therapy Travel Fact Sheet [PDF - 370KB]
Pharmacy Benefits
- Formulary Prior Authorization and Exception Form [PDF - 455 KB]
- CVS Mail Order Fax Form [PDF - 650 KB]
Out-of-Pocket Reimbursement of Medical Costs
- Reimbursement Request Form - English [PDF - 1.96 MB]
- Reimbursement Request Form - Spanish [PDF - 1.51 MB]
HSCSN Benefits
- Benefits Covered [XLS - 1.79 GB]
Behavioral Health
- AprilMay Referral Form [PDF - 719 KB]