Be sure to include your Insurance Information Exchange Account Number. • Fill in the following blocks in Part A: Name, address, city, state, zip code, company,.Information can be computer-filled, or you can print out the form and hand-fill it. Send completed form with required documents to the address above. Below is the list of plans that are accepted at Cleveland Clinic main campus, our family health centers and community hospitals in Northeast Ohio. Use our forms to help manage your health plan and flexible spending account (FSA). If someone is helping you fill out this application, you may need to complete Appendix C. Apply faster online at HealthCare. Gov or benefits.Ohio.gov. This documentation is typically called a certificate of coverage, or it could be a letter from another insurance or employer. Members can log in to view forms that are specific to their plan.