1 General Forms
Summary of Benefits and Coverage
These documents describe what the plans cover and what they cost.
This document outlines of your medical, dental & vision coverage.
Use this form to let us know if you want to allow someone other than yourself to discuss your health information. This could be your wife or husband, a relative, an attorney and so on.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
This document contains information regarding medical child support orders.
To provide information about possible other coverage.
Use this form for filing claims incurred from a non-network provider.
This document explains how to access the Health Risk Appraisal Online
1 Prescription Drug Forms
With our PDL, you and your doctor have the freedom to choose the medication that works best for you.
List of participating chain and independent retail pharmacies.
Use this form to process prescription drug orders under the mail service plan.
Use this form to obtain reimbursement for a prescription drug.
1 Self Funded Forms
Use this form as a guide to read your Explanation of Benefits for claims.
Use this form to send dental claims to us.
Use this form to file a vision benefit claim.
Use this form to let us know if health care was the result of an accident.
Use this form to let us know if you will be getting a settlement payment for an accident from another person or business. This form lets us know that we will be reimbursed for any treatment we have paid for due to that accident.
Use this form to let us know if there have been any changes that would affect your insurance, such as a spouse getting or losing coverage under other insurance, or if a child has become or is no longer a full time student.
Use this form to file a claim with medical bills and Prescription Drug receipts.
1 Flexible Spending Account (FSA) Forms
Use this form to send claims to us for your Flexible Spending Account.
Use this form to determine if health expenses are covered under your Flexible Spending Account.
Use this form to determine if expenses for your child's care are covered under your Flexible Spending Account.
Use this form if your employer offers a Flexible Spending Account and you need to indicate if you will or will not be participating.
1 Miscellaneous Forms & Documents
This document explains the top reasons why a medical claim could be denied.
Medicaid and the Children’s Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families.
Information about this free service from your employer.