Member Benefit Request Form

Easily request membership eligibility and behavioral health benefits online with the Membership Eligibility and Benefit Request Form. When you submit this form, one of our membership service representatives will respond to your request within one (1) business day. You may also call Quest Behavioral Health at 800-364-6352 or 717-851-1480 to verify membership eligibility and benefits.

  • Member Information

  • Benefits

    Select all that apply

  • Contact Information