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	Download
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	187 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 moc.s1734787106elpir1734787106topur1734787106g.dul1734787106as@co1734787106dlort1734787106noc1734787106 , 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
Claim for International Travel Insurance issued by Triple-S Vida (Reimbursement) Access the online Reimbursement Form to submit a request for a reimbursement under the International Travel Insurance. You will be redirected to pipefy.com		Video Tutorial Reimbursement Form

HIPAA Forms

Documents	Size	Download
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.	501 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	Download
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
Consent Informed on treatment form Beneficiary request to receive Behavioral Health Provider Services according to the evaluation and treatment that understand necessary for the patient’s welfare. Consent Informed on treatment offered for Mental Health Provider for stabilization and welfare of beneficiary.	289 KB	Download

Notice of Changes to Formulary

DOCUMENTS

Triple-S notifies the following changes to its Pharmacy Form:

Effective Changes at 03/15/2024

Effective Changes at 10/15/2024