If you are a member experiencing a critical illness, injury, or behavioral health problem and believe you could benefit from The Health Plan Case Management Program , please fill out and submit the form below.

You can also contact the case managers by calling the Medical Department at 740.695.7644 or 740.695.7643 and toll-free at 1.800.624.6961, ext. 7644 or 7643.

Fields listed with an "*" are required.

Required *

Member Name  *

Please type your Member Name

Member ID  *

Health Plan ID Number must be nine characters and begin with an H

Member's Phone Number  *

Please include your phone number. Do not include spaces

Member's Email

Member's Physician

Please indicate a reason for case management in field provided