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NALC CDHP Forms — Easy Access, Simple Submission

Quickly find and complete the forms you need to manage your NALC Consumer Driven Health Plan (CDHP). Whether it’s filing a medical claim, managing prescriptions, or requesting privacy changes—we’ve got the tools to help.

All the essential forms you may need for your Consumer Driven Health Plan are here. Whether you're filing a claim, seeking reimbursement, or updating your coverage details—you'll find what you need.

Download and submit prescriptions, claims and Medicare- related forms. It's your one-stop hub for staying organized and covered.

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Caremark Forms

Use these forms for prescriptions fulfillment and reimbursement under your NALC Consumer Driven Health Benefit Plan.

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Submit this form with your prescriptions and payment to receive medications by mail.

Download Mail Order Prescription Form

Submit this form for the reimbursement of short-term prescriptions received at non-network or retail pharmacies. Receipts are required.

Download Short-Term Prescription Form

Claim Forms

Submit claims for care you received while covered under the NALC Consumer Driven Health Plan.

Request reimbursement for eligible medical services.
Mail to:
NALC CDHP, PO Box 188050, Chattanooga, TN 37422-8050

Member Medical Claim Form

Submit this form when you or a dependent has other insurance coverage (health, auto, or Medicare).

Download Important Questionnaire
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Privacy Forms

Take control of who can access your health records through your NALC Postal CDHP.

HIPAA Privacy Notice

Understand how your Protected Health Information (PHI) is handled.

Get HIPAA Privacy Notice

Authorized Representative Form

Give someone permission to speak on your behalf regarding CDHP benefits.

Get Authorized Representative Form

Request for Access to PHI

Request a copy of your personal health records from NALC HBP.

Request Access to PHI

Request for Alternate Address

Safeguard your information by requesting mail at a different address.

Request Alternate Address

Authorization for Release of Information

Authorize us to share your PHI with at third party (eg., an insurer or new provider).

Get Authorization for Release Information

Mail all completed forms to:
Privacy Officer - NALC Health Benefit Plan
20547 Waverly Court - Ashburn, VA 20149

SilverScript® Prescription Drug Program Forms

For Medicare-eligible CDHP members using the SilverScript® Prescription Drug Program (PDP).

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Submit this form to enroll in the SilverScript Medicare PDP (Part D).

Get Enrollment Form

Submit this form to disenroll from SilverScript PDP (Part D).

Get Disenrollment Form

Submit this form along with your prescriptions and payment for mail-order medications through SilverScript.

Get Mail Order Prescription Form

Submit this form to request reimbursement for eligible Medicare Part D prescriptions.

Get Medicare Part D: Prescription Claim Form

Travel Prescription Request Form

Traveling soon? Ensure you're covered.

Submit this form to request an early refill of your regular prescriptions before you travel. Submissions must be received prior to departure.

Download Travel Form

2024 Massachusetts Schedule HC

Massachusetts residents must verify health coverage when filing state taxes.

Schedule HC Form + Instructions
NALC HBP qualifies as Minimum Creditable Coverage. Use this form when submitting your MA tax return.

We're Here to Help - Contact and Support

Your questions matter. Reach out for help with your NALC Consumer Driven Health Plan forms or coverage.

NALC HBP Member Services

For general plan questions, our team is ready to assist you

Go to Contact Page

Download Your Plan Brochure

For all the detailed information on your benefits—including exclusions and limitation —please download your official Plan Brochure.

Download Plan Brochure PDF

Frequently Asked Questions (FAQs) — Quick Answers for You

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Once you complete a form, check the instructions on that specific form. Most forms will have a mailing address printed directly on them, such as the Chattanooga, TN address for medical claims or the Ashburn, VA address for privacy requests. Always send your forms to the address listed, or follow the submission method provided—some forms allow fax or electronic submission.
If you paid out of pocket at a non-network pharmacy, or for short-term needs, complete the Short-Term Prescription Claim Form and include your detailed pharmacy receipt. If you have Medicare Part D, use the SilverScript Prescription Claim Form.
Yes. To give another person permission—such as a spouse, caregiver, or family member—submit the Authorized Representative Form under the HIPAA Privacy section. Once approved, that person will be able to speak with the Plan about your benefits, claims, and coverage on your behalf.
If you have upcoming travel, complete the Vacation Prescription Request Form. This form allows you to receive an early refill so you don’t miss doses while you’re away.
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