Last Audited 6/28/2014

Great-West Healthcare Forms

Form Number Revision Date

Form Name

(Links to Plan Source Library)

Internal Use

M4468 11/07 Medical Enrollment Form RA IA/IU
827183a 2/13 Vision Claim Form EA  
591692c 9/12 Medical Claim Form EA  
590154e 3/13 Dental Claim Form EA  
583522i 12/12 Prescription Drug Claim Form EA  
3300 N/A Prescription Mail Order Form RA  
839773 10/10 Flexible Spending Account Reimbursement Form EA  
827378 10/10 Flexible Spending Account Status Change Form EA  
Texas Forms
M4451H-TX 3/05 Enrollment/Change Form RA IU
Link directly to forms section of Great-West Healthcare's website



Please be advised that the forms in the PlanSource Library are only as current as the forms on the carrier’s web sites.  More and more carriers are requiring a user ID and password to access the forms section of their site, so it may delay PlanSource access to updated forms.  To access the most up to date forms, users may need to register with the carrier to obtain a login. 


Please note:  Any form in the PlanSource Library that is coded "RA" means that we are unable to locate the form on the carrier's website.  You may need to contact your carrier representative or broker to obtain the most current form.

If you can't find the form that you're looking for, please contact your insurance broker or HR Administrator.