Member Forms

Title
pdf ACH Wire Transfer Form - If you wish to have any reimbursements payable to you to be directly deposited into your account, you may fill out this form, and the information will be securely kept on file. If you need to make a change, simply submit a new form. Download
pdf Proof of Loss Form - If you are covered under the Health Benefit Plan 1-3 and have paid for services out-of-pocket, this form must be completed and returned to IMG along with a detailed bill, payment receipts and PC authorization form. Download