Forms
- Premise Onsite Clinics
- Adoption & Maternity
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- Appeals
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Appeals – First Level
Medical Necessity or Infertility (BCBS)
Medical Necessity or Infertility (UHC)
Medical Necessity or Infertility (UMR)
Rehabilitative Services (BCBS)
Usual and Prevailing Fee Allowance (BCBS)
Usual and Prevailing Fee Allowance (UHC)
Appeals – Second Level
Medical Necessity or Infertility (BCBS)
Medical Necessity or Infertility (UHC)
Medical Necessity or Infertility (UMR)
Rehabilitative Services (BCBS)
- Disability
- Eligibility
- Claims
- Health
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Flexible Spending Account
Dependent Care FSA Stop Deductions
Prescription Drug
BCBS Medicare Part D Claim Form
UHC Medicare Part D Claim Form
Health Insurance Portability and Accountability Act (HIPAA)
Medicare Crossover Enrollment
BCBS: Contact Customer Service
UHC: Medicare Crossover Enrollment Form
Medicare Part D Form
BCBS Medicare Part D Claim Form
UHC Medicare Part D Claim Form
Transition of Care
- Life / AD&D
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Life Insurance
Life Insurance Portable Coverage
Proof of Good Health – MetLife
American Airlines Medical Plans (PDF)
US Airways Medical Plans (PDF)
AD&D
Accidental Dismemberment Claim Form
Conversion Information and Form
Death Benefits/Accelerated Option
- Retiree
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Retirement forms can be found on Jetnet