Mhbp form 2026

1. Click ‘Get Form’ to open the mhbp form in the editor.
2. Begin by filling out the Member Information section. Enter your last name, first name, middle initial, and member ID number accurately.
3. Next, complete the Patient Information section if the claim is for a qualified dependent. Include their last name, first name, patient ID, date of birth, relationship, and gender.
4. If applicable, provide details in the Accident Information section. Specify the date of the accident or first symptoms and indicate if it’s work-related.
5. Fill out Medicare Information only if eligible. Attach a copy of the Explanation of Benefits from your Medicare carrier.
6. Complete the Other Health Insurance section if you have additional coverage. Provide policyholder details and insurance company information.
7. Sign in the Authorization/Release of Information section to allow processing of your claim and in the Assignment of Benefits section to authorize direct payment to your provider.
8. Finally, check with your provider about filing claims on your behalf. If not, attach all necessary documents and mail them to the address provided on the form.

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