Insured Forms

The forms listed on the menu below are for use of members. Some of these forms are in portable document format (PDF). You may print and copy these as needed. Some forms are applications that can be completed and submitted online.

Transactions Forms

Documents Size 2017
Reimbursement for Medical / Dental Services

Form to submit a reimbursement petition online for medical and dental procedures. The form must be completed in its entirety and payment receipts must be included to avoid any delay in the process.

0 KB Online form
Reimbursement for Medical Services

Form to submit a medical reimbursement petition. The form must be completed in its entirety and payment receipts must be included to avoid any delay in the process. Reimbursement claims can be delivered to our Customer Service Centers or through the mail to: Triple-S Salud, Reimbursement Department PO BOX 363628 San Juan PR 00936-3628

402 KB Download
Reimbursement for Dental Services

Form to submit a dental reimbursement petition. The form must be completed in its entirety and payment receipts must be included to avoid any delays in the process. Reimbursement claims can be delivered to our Customer Service Centers or sent by regular mail to: Triple-S Salud, Claims Department, Dental Section PO BOX 363628 San Juan PR 00936-3628

373 KB Download
Cancel / Enroll Dependents

Form to be completed by Triple-S Directo and Puerto Rico Government employees to enroll or cancel dependents in their health plan. The information can be sent by email to controldoc@ssspr.com , by fax at (787) 706-2833, or by regular mail to: Customer Service PO Box 363628 San Juan, PR 00936-3628. These requests are subject to enrollment rules previously established. Please refer to your policy for more details. Group Policy members must verify the certificate of benefits for information on eligibility and may be required to submit their requests through their group administrator.

185 KB Download
Electronic Funds Transfer(EFT)

Form to authorize a direct debit to a checking or savings account or to a preferred credit card to pay for the health plan premium.

131 KB Download
Coordination of Benefits

Form to be submitted when you have more than one health insurance plan so that your benefits can be coordinated. The completed Coordination of Benefits Form must be mailed to: Coordination of Benefits Section Triple-S Salud PO BOX 363628 San Juan, PR 00936-3628

1.152 KB Download
Report Fraud and Abuse

If you have information or suspect a health insurance fraud or abuse may have been committed, you can contact Triple-S Salud through the Fraud and Abuse confidential line at (787) 277-6633, Monday through Friday from 8:00 AM to 4:30 PM. If you wish to report it online, you can access this link to the Referral of Possible Cases of Fraud and Abuse Form.

0 KB Online form

HIPAA Forms

Documents Size 2017
Access Request

Form to request copies of protected health information that Triple-S Salud or its business partners keep in a specific format.

21 KB Download
Amendment Request

Form to request to amend the protected health information that Triple-S Salud or its business partners keep. Evidence most be present to justify the amendment.

20 KB Download
Disclosure Report Request

Form to request reports of disclosures of personal health, financial and insurance information.

21 KB Download
Request to Restrict the Use or Disclosure of Health Information

Form to request the restriction of the use and disclosure of protected health information.

21 KB Download
Authorization to Disclose Protected Health Information

Form to authorize Triple-S Salud to disclose protected health information.

84 KB Download
Confidential Communication Request

Form to request the health insurance plan to use alternate means or an alternate address to send his/her health information.

27 KB Download
Revocation of Authorization

Form to revoke or confirm the revocation of an authorization previously granted.

27 KB Download
Complaints

Form to submit complaints regarding the health insurance plan compliance with privacy practices.

24 KB Download

Application for Medical Exception

Documents Size 2017
Application for Medical Exception

Application to request a medical exception for medications not covered by the formulary, drug discontinuation for reasons other than safety or recall by the manufacturer, or exception to the step therapy or dose limitation.

412 KB Download

Keep me informed

In Triple-S Advantage we want to inform you about important health topics.

loader
+