About Broker Resources Provider Resources 330-363-6360 Contact Us Account Login Member Resources Home Member Resources Member Forms Everything You Need for Your Health Coverages Manage your AultCare account with a full complement of member forms — for claims, HIPAA guides, other coverages, other AultCare departments, and more. AultCare Account Login / Register Account Login Register for an Account Claim Forms Accident Questionnaire — Provide additional information regarding accident or injury. Accident Questionnaire - Spanish — Cuestionario de Accidentes Proporcione información adicional sobre accidentes o lesiones. Dental Claim Form — Form & instructions for filing a Dental Claim. Flexible Spending Claim Form (Medical) — Instructions and form to submit Health Care Spending Account claim for reimbursement of medical expenses. Request a Member Card Replacement Medical/Rx Claim Form — Form & instructions for filing a Medical/Rx Claim. Vision Claim Form — Form & instructions for filing a Vision Claim. HIPAA, Guides, & Directives Advanced Directives — The Ohio Hospice and Palliative Care Organization offers an online packet of the Advance Directives Forms. Member Guide Multi-language Interpreter Services/Non-discrimination Notice — Multi-language Interpreter Services/Non-discrimination Notice. Referral and Prior Authorization Guidelines — Instructions regarding pre-certification (pre-approval/pre-authorization). Sample Explanation of Benefits — Consolidated Explanation of Benefits sample with instructions on how to read your CEOB. HIPAA Forms HIPAA Access Request Form — Members can use this form to access their insurance Protected Health Information (PHI) from AultCare. Please route this request to the Privacy Coordinator at AultCare. Please allow a 15 day turnaround response time for this request. HIPAA Amendment Request Form — Members can use this form to request a change to the Protected Health Information (PHI) AultCare has on file. This can be used if the member has found an error in their PHI. HIPAA Confidential Communication Request Form — Members can use this form to request their Explanation of Benefits (EOB) or other AultCare communications are confidentially sent to a different address than what is on file or phone calls are made to a different phone number. If you feel harm may be caused if your information is sent to anyone outside of you, please complete the Member Request to Restrict Uses and Disclosures Form. HIPAA Designation of Authorized Representative Form — Members can use this form to designate someone other than you to speak to us on your behalf. Legal documentation (such as a General or Durable Power of Attorney or Guardianship) is required to allow an Authorized Representative to make actual changes on your behalf. HIPAA Member Restrict Uses and Disclosures — Members can use this form to limit who has access to their Protected Health Information (PHI). Other Coverage Forms Continuation Of Coverage Form — For a child who is incapable of self-sustaining employment by reason of mental or physical disability and who has reached the limiting age for dependent children specified in the plan or contract. Or for the continuation of dependent coverage for college students (FTS) who would otherwise lose eligibility because of a reduction in their full-time class status or a medically necessary leave of absence from the school itself. Flexible Spending Claim Form (Dependent) — Instructions and form to submit Dependent Care Account claim for reimbursement of dependent care expenses. Full-Time Student Verification Form — AultCare verifies dependent information annually to ensure that claims are processed according to your plan's guidelines. Notification required within 30 days if dependent's full-time status changes dependent does not meet Health Plan guidelines. Other Coverage Information Form — Printable form for other coverage information. Other Coverage Information Form (electronic) — Electronic version of the "Other Coverage Information Form." Other Coverage Information Form (including Timken) — Printable form for other coverage information. Preventive Care, Benefits, and Services — Printable flyer listing suggested preventive care guidelines to discuss with your Primary Care Physician (PCP). Other AultCare Departments Pharmacy Forms PPACA Self-Funded Grandfathered Plan Dep Age — This form is required for groups with a grandfathered status for enrolling a dependent from the ages of 19-26. This form must accompany a completed enrollment form for the dependent. Primary Care Physician — Primary Care Physician (PCP) selection medical information release authorization. AultCare Authorization for Direct Deposit for Short Term Disability — Authorizing AultCare to deposit pay automatically to the account indicated. Appeals & External Review Internal Appeal Request Form — If you disagree with a determination decision about a specific benefit, you have the right to file an internal appeal with AultCare using this form. You may also submit your appeal in writing and include any written comments, documentation, or records relevant to your appeal. AultCare Treating Physician Certification for Experimental or Investigational ABD — You may have your provider complete this form if your request for benefit determination has been denied as Experimental or Investigational. (We do not require the completion of this form, but provide it for your convenience. Your provider must certify to us in writing that your request is of an expedited nature before we will proceed with it as an expedited appeal.) AultCare Treating Physician Certification for Internal Appeal and/or External Review — You may have your provider complete this form if your request for benefit determination has been denied and you are requesting an expedited appeal or review. (We do not require the completion of this form, but provide it for your convenience. Your provider must certify to us in writing that your request is of an expedited nature before we will proceed with it as an expedited appeal.) External Review Request Form — If you disagree with our appeal decision and have exhausted your internal appeal rights, you can request an External Review using this form. (For Insured and Public Employer Plans only.) AultCare Request for Review by the Ohio Department of Insurance — If we have denied your request for an External Review and you disagree with our decision, please use this form. External Review Procedures Summary — An explanation of the External Review procedure for all Insured and Public Employer Plans effective 02/2012. Contact Info Have a Question? AultCare Customer Service Hours: 7:30 am to 5:00 pm EST. AultCare Service Center 330-363-6360 1-800-344-8858 TTY Line 711 Timken Service Unit 330-363-2682 1-800-505-2858 Additional Information Pharmacy Services Pharmacy Services Care Coordination Recommended Preventive Care by Age and Gender Health Library and Self-Management Tools Referral & Prior Authorization Guides Health Talks Calendar Transparency Physician & Hospital Information Validation Transparency in Coverage (Individual) Transparency in Coverage (Small Group) Provider Information Provider Directory Network Hospitals & Facilities Locations List Aultra Providers Teledoc/After Hours Care DenteMax Member Information How to find an In-Network Pharmacy Cigna PPO Network Information Find A Provider Guide (Cigna) Marketplace Payment Information Member Guide Privacy Information Enrollee Rights & Responsibilities Language Access Quality Outcomes AultCare Mobile App Download access to your Member Portal through either app store. AultCare Phone: 800-344-8858 330-363-6360 TTY: 711 24-Hour Nurse Line: 866-422-9603 330-363-7620 Customer Service Hours: Monday - Friday 7:30 am - 5:00 pm EST Mailing Address: 2600 Sixth St S.W. Canton, OH 44710 IRS Notice 2020-76 AultCare Insurance Company will not be automatically mailing 2020 Form 1095-Bs to members. However, upon request, any applicable members can have their 2020 Form 1095-B. To receive your 2020 IRS Form 1095-B, submit the request via our CONTACT US on our website or send the request to: AultCare Insurance Company 2600 Sixth ST SW Canton, OH 44710 You can also call us at 330-363-6360 or 800-344-8858 with any questions. Your request will be furnished within 30 days of receipt. Additional Resources HIPAA Privacy Policy Terms & Conditions Language Access Quality Careers COVID-19 Information Social Non-discrimination Notice AultCare/Aultra complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sexual orientation, gender identity, or sex. AultCare/Aultra does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. AultCare/Aultra provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats). AultCare/Aultra provides free language services to people whose primary language is not English, such as: Qualified interpreters and information written in other languages.If you need these services, or if you believe that AultCare/Aultra has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can contact or file a grievance with the: AultCare/Aultra Civil Rights Coordinator, 2600 6th St. S.W. Canton, OH 44710, 330-363-7456, CivilRightsCoordinator@aultcare.com. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Civil Rights staff is available to help you.You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html © 2021 AultCare. All rights reserved.