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Clinical Review Criteria

Atlantis Rewards Program


Employer Update/Termination/Deletion Form Credit Card Authorization
Atlantis Rewards Program Application Enrollee Authorized Designee Form
Age 29 Enrollment Form - Group Employees Age 29 Enrollment Form - Direct Pay.pdf
Member HIPAA Release Form HealthWarehouse Generic Mail Order Form

Instructions When Completing Atlantis Heath Plan Claim Form

  1. Complete Sections 1-13 to the best of your ability
  2. Complete new form for each member of the family that you are submitting medical expenses
  3. New forms must be used on subsequent submissions
  4. Photo-copy or faxes are not acceptable
  5. Mail claims to address listed on upper right corner of HCFA 1500 form
  6. Adherence to these guidelines will enable us to process your claims in at timely manner.
Health Insurance Claim Form (HCFA 1500)

If you have any questions contact our Member Services Department at 1-866-747-8422. Member claims should be mailed to 45 Broadway, Suite 300, New York, NY 10006.