There are a number of forms you need on a regular basis to receive the benefits under your plan. These forms can be downloaded and printed using Adobe Acrobat® software. If Acrobat® is already installed on your machine, you can click on any one of the links below to immediately access the form.

Forms & Document Library

Caremark Mail Order PDF | 100 kb: Caremark Mail Order Service Form

COB PDF | 350 kb: COB Form

Dental Claim PDF | 274 kb: ADA Dental Claim Form

Dentist Nomination PDF | 304 kb: Dentist Nomination Form

Doctor Nomination PDF | 564 kb: Physican Nomination Form

HRA Direct Deposit PDF | 61 kb: HRA Direct Deposit Form

HRA Reimbursement PDF | 77 kb: HRA Reimbursement Form

HSA Beneficiary Form: HSA Beneficiary Designation Form

HSA Deposit Form: HSA Deposit Form

HSA Enrollment Form and Banking Agreement: HSA Enrollment Form and Banking Agreement

HSA Withdrawal Form: HSA Withdrawal Form

JPMC HSA Closure Request Form: JPMC HSA Closure Request Form

Lab Reminder PDF | 1 mb: Lab Savings Program Reminder Card Form

Medical Claim PDF | 218 kb: Medical Claim Form

Overseas Claim PDF | 1.5 mb: Overseas Medical Claim Form

Pharmacy Claim PDF | 80 kb: Pharmacy Claim Form

Travel Form PDF | 240 kb: Travel Reimbursement Request

Adobe Reader: To view and print PDF files, download and install the latest version of Adobe Reader.

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Forms & Document Library

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