Member Forms

Family Health Network Member FormsTo look at a form or to print a form, click on the link below:

English

ACAP Scholarship Application
Brighter Beginnings Enrollment Form
Children’s Book Club Form - English/Spanish
Grievance and Appeals Form
Health Risk Survey
HIPAA - Personal Representative Form
Mammogram Incentive Form
Photo Release Form
Toddler Book Club Form
Vision Rebate Coupon

 

Spanish

Formulario de inscripción en el Programa Brighter Beginnings
Formulario del Club infantil del libro - Inglés/Español 
Formulario para el representante autorizado
Cuestionario de riesgos de salud
HIPAA - Formulario de Representante Personal
Formulario de incentivo para mamografía
Formulario de divulgación de fotografía
Club Infantil del Libro
Cupón de reintegro de gastos relacionados con la vista


Please call Member Services if you would like any of these forms mailed to you. The phone number to call is at 1-888-346-4968 TTY: 711.

 



 

Member Services

If you have a question about your health plan, please call Member Services.  Hours are 8 a.m. to 5 p.m. Monday through Friday and 9 a.m. to 1 p.m. Saturday.


Si tiene preguntas sobre su plan de salud, por favor llame a la línea de Atención a Miembros Participantes. Horario de 8 a.m. a 5 p.m. de Lunes a Viernes y Sábado de 9 a.m. a 1 p.m.

1-888-FHN-4YOU
(346-4968)
TTY: 711

FLU Season

Flu season begins in October and lasts as late as May. Talk to your doctor about getting a FREE flu shot today.

Click here for more information

Service Area

FHN serves people living in the Chicago area: including Cook, DuPage, Kane, Kankakee, Lake and Will Counties.

Service outside of our Service Area

If you are not in our service area and you need care but it is not an emergency, please call us at 1-888-346-4968 TTY: 711. We will work with you to help you get the care and services you need. When FHN helps to arrange non-emergency services for you outside its service area, we will cover the cost. If you get services outside of our coverage area, we may not pay for those services.
If you are not in our service area and you need emergency care, call 911 or go to the nearest hospital.