Insured Forms

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

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

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@ , 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.

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.

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

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

Access Request

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

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.

Disclosure Report Request

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

Request to Restrict the Use or Disclosure of Health Information

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

Authorization to Disclose Protected Health Information

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

Confidential Communication Request

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

Revocation of Authorization

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

Complaints

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

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.

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.