Forms

Premise Onsite Clinics

Premise New Patient Packet

Premise Travel Medicine Questionnaire

Premise Biometric Patient Forms

Adoption & Maternity

Adoption Assistance Reimbursement Form

Post Pregnancy Maternity Short Term Disability Plan Form

Appeals

Appeals – First Level

Administrative Issues

Dental Services

Disability

Pilot Long Term Disability

Medical Necessity or Infertility

Plan Exclusions

Prescription Drugs

Rehabilitative Services

Usual and Prevailing Fee Allowance

Appeals – Second Level

Administrative Issues

Dental

Disability Coverage

Medical Necessity or Infertility

Plan Exclusions

Prescription Drugs

Rehabilitative Services

Usual and Prevailing Fee Allowance

Disability

Disability Claim Form

Post Pregnancy Maternity Short Term Disability Plan Form

Disability Enrollment Form

Pilots

Disability Coverage (Pilot LTD), First Level Appeal

Long Term Disability Claim Form

Statement of Health – MetLife

American Airlines Medical Plans (PDF)

US Airways Medical Plans (PDF)

Eligibility

Common Law Marriage Recognition Request

Disabled Dependent

Declaration of Domestic Partnership (Travel Only)

Claims

Medical

Blue Cross Blue Shield Claim Form

UHC Claim Form

Dental

Dental Claim Form

Vision

EyeMed Out-of-Network Claim Form

Death Benefits/Accelerated Option

Death Benefit Accelerated Claim Form

Prescription

Prescription Reimbursement Claim Form

AD&D

Accidental Death Claim Form

Accidental Dismemberment Claim Form

Conversion Information and Form

 

Health

Flexible Spending Account

Dependent Care FSA Stop Deductions

How to Submit Manual Claims

Prescription Drug

Express Scripts Mail Order Form

Health Insurance Portability and Accountability Act (HIPAA)

HIPAA Authorization Form and Instructions

HIPAA Complaint Form

HIPAA Notice

Medicare Crossover Enrollment

BCBS: Contact Customer Service

UHC: Medicare Crossover Enrollment Form

Medicare Part D Form

Medicare Part D Claim Form

Notice of Creditable Coverage

BCBS Prescription Drug Reimbursement

UHC Prescription Drug Reimbursement

Transition of Care

Medical Transition of Care Form

Life / AD&D

Life Insurance

Life Insurance Portable Coverage

Statement of Health – MetLife

American Airlines Medical Plans (PDF)

US Airways Medical Plans (PDF)

AD&D

Accidental Death Claim Form

Accidental Dismemberment Claim Form

Conversion Information and Form

Secure Travel Protection

Retiree

Retirement forms can be found on Jetnet