Forms

Authorization to Release Information
SIHO respects your personal health information. To comply with new HIPAA legislation, this authorization form is needed if anyone outside of your household is to be authorized to receive your or your dependant’s PHI.

Medical Claim Form
Dental Claim Form
Security Life Dental Claim Form (for Fully Insured Accounts)

Deaconess Out of Network Referral Request Form

Flex Account Claim Form
Flex Direct Deposit Form



Short Term Disability Claim Form

Transition of Care Form

Fully Insured Group Forms and Information
Change Request Form:
  • Add new dependents
  • Change of address
  • Change in marital status
  • Terminate an employee's / member's health coverage

Employee Enrollment Form I: Employee application for Small Groups (2 to 50)

Employee Enrollment Form II: Employee application for Large Groups (51+)

Employer Application Form

New Member Information

Preventive Health Benefit: Information about covered preventive services

Please complete the necessary forms and send them to:

SIHO Insurance Services
417 Washington Street
Columbus, IN 47201
Fax: 812-348-4590

Attn: Carolyn Dailey


Health Savings Account Forms



Provider Forms


SIHO Provider Manual
Member Submit Medical Claim Form
Physician Claim Form HCFA 1500
Physician Dental Claim Form
SIHO Prior Authorization Request Form
Authorization to Release Information (PHI)
Clean Claim Letter
ProviderDataSheet
W-9

Outpatient Mental Health

Outpatient Mental Health Initial Treatment
Outpatient Mental Health Continued Treatment Plan
Outpatient Mental Health Treatment Process
Applied Behavioral Analysis (ABA) Treatment

Speech Therapy

Discharge Assessment

SIHO's Preventive Health Benefit

Preventive Health Benefit Details

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