Benefit and Claim Information Authorization Release Form - Use when the release benefit, claim, or personal information is required.
Incident Questionnaire - You may be asked to complete this form after sustaining an injury or being involved in an accident.
Member Submitted Claim Form - Submit a medical or vision claim when the healthcare provider is not submitting it on your behalf.
Medical Travel Support Claim Form for Bariatric Surgery - Use this form to be reimbursed for certain travel expenses when you have approved travel 50 miles or more from your home or residence for medically necessary bariatric surgery procedures.
Non-Disclosure Request - Tell us your requests about sharing your health information.
Request for Certification of Disabled Dependent - Disabled Dependent Certification Form – You may be asked to complete this form for your disabled dependent child to ensure they meet the group’s eligibility requirements for continued coverage after the age limits are reached.
Express Scripts Home Delivery Mail-Order Form
- Complete this form to have Express Scripts fill your prescriptions by mail.
Health, Allergy & Medication Questionnaire
- Complete this questionnaire for all new mail prescriptions to help protect yourself against potentially harmful drug interactions and side effects.
Prescription Drug Reimbursement Form
- Apply for reimbursement of your prescription costs.
Secondary Insurance Prescription Drug Claim Form
- Complete this form if you have secondary prescription coverage and want to be reimbursed.
Healthcare Flexible Spending Account (FSA) Claim Form - Need to file a Flexible Spending Account claim for Reimbursement? Start here.
Dependent Care Flexible Spending Account Claim Form - Need to file a Dependent Care Flexible Spending Account claim for Reimbursement? Start here.
Dependent Care FSA