Health Care and Benefits Division

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Benefit Forms

New Enrollment/Qualifying Event Forms

2010 Group Benefit Enrollment/Change Form (pdf)

2010 Flexible Spending Enrollment/Change Form

Life Insurance Enrollment/Change Form (pdf)

Evidence of Insurability (Medical History Form)

Declaration of Domestic Partner Relationship Form

Domestic Partner Dissolution Form

Reimbursement Forms

URx Direct Member Reimbursement Form (pdf)

Caremark Direct Member Reimbursement Form (pdf)
Required information that needs to be on your receipt for reimbursment:
National Drug Code (NDC)
Quantity Dispensed
Day Supply Dispensed

EyeMed Out-of-network Claim form

Allegiance Flex Advantage Medical Expense Reimbursement Request Form

Day Care Reimbursement Request Form

URx Pharmacy Forms

Ridgeway Prescription Drug Mail Order Form (pdf)

MedVantx (AmeriPharm) Mail Order Form (pdf)

Plan Exception Form

Authorization Forms

BCBS out of state travel preauthorization form

HIPAA Privacy Notice and Authorization Form (pdf)

Active Duty Forms

Instructions

Insurance Election form

Insurance Reinstatement form

Pre-Retirement Forms

Retiree Election Form (pdf)

Retiree Election Form (Example) (pdf)

Pre-Payment Option Form (pdf)

Electronic Premium Deduction Authorization Form

Certificates and Policies

Long Term Disability Certificate

Accidental Death and Dismemberment policy

Life Insurance Certificate