Member Forms

ENCOMPASS offers members online forms as an easy way to contact us regarding a service need. You can also contact ENCOMPASS by calling the toll-free phone number on your health plan identification card.

To use an online form, select from the following:

• Medical Review Request Form
  Patients and family members may use this form to request a medical review (sometimes referred to as precertification).

• Maternity Management Enrollment Form
  Maternity patients may use this form to request enrollment in our Maternity Management program.

• Notification for Golden Rule
  Patients and family members may use this form for Golden Rule Insurance Company notification requirements.

• Network Customer Service Request Form
  Patients and family members may use this form to submit an ENCOMPASS network customer service inquiry.

• Baxter Referral Form
  Baxter members may use this Primary Care Network (PCN) Physician Referral Authorization Form.

• Contact Us
  Use this form to submit general questions, concerns, inquiries, or requests related to ENCOMPASS or our services.