Forms & Resources

We are committed to keeping you up-to-date on all aspects of your benefit plan. Whether you need to request a new ID card for an employee or download an important form, you can find it all here.

Would you like to:

Download the Administrative Guide PDF icon

Print a form for yourself

Print a form for a member

Order an ID Card or print a temporary card for a member


Forms for Employers

Authorization

PDF icon Employer Portal Access Form

COBRA Enrollment

PDF icon COBRA Qualifying Event Termination

Forms for Members

 Authorizations

PDF icon Online Access / PHI Disclosure Form

PDF icon Member Authorization to Obtain PHI

PDF icon Member Authorization to Release PHI

Flexible Spending Account (FSA) & Health Reimbursement Arrangement (HRA)*

PDF icon FSA Claim Form

PDF icon HRA Claim Form

PDF icon FSA-OTC Claim Form

PDF icon FSA Transit/Parking Claim Form

PDF icon FSA/HRA Direct Deposit Form

Member Appeal

PDF icon Member Appeal Form

Member Reimbursements*

PDF icon Standard Medical Claim Form

PDF icon Standard Dental Claim Form

PDF icon Member Reimbursement Form  green starsubmit your request in My Plan

PDF icon Short Term Disability Form

PDF icon Fitness Reimbursement Form  green starsubmit your request in My Plan

PDF icon Weight Loss Reimbursement Form  green starsubmit your request in My Plan

 

*Claim and reimbursement forms may not be applicable to all plans. Be sure to check your benefit details in your summary plan description prior to submitting a claim or reimbursement form.

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