There are a number of forms you need on a regular basis to manage your benefits. 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

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 Authorization: HSA Authorization/Enrollment 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

Caremark Mail Order PDF | 100 kb: Caremark Mail Order Service 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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Access My Online Services where you can view claims, print EOBs and ID cards, update your personal health information, take Health Risk Assessments, manage your HRA or HSA and much more. Get a preview of My Online Services.

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Forms & Document Library

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