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

Disability

Pilot Long Term Disability

Medical Necessity or Infertility (BCBS)

Medical Necessity or Infertility (UHC)

Medical Necessity or Infertility (UMR)

Plan Exclusions (BCBS)

Plan Exclusions (UHC)

Prescription Drugs

Rehabilitative Services (BCBS)

Rehabilitative Services (UHC)

Usual and Prevailing Fee Allowance (BCBS)

Usual and Prevailing Fee Allowance (UHC)

Appeals – Second Level

Administrative Issues

Dental

Disability

Pilot Long Term Disability

Medical Necessity or Infertility (BCBS)

Medical Necessity or Infertility (UHC)

Medical Necessity or Infertility (UMR)

Plan Exclusions

Prescription Drugs

Rehabilitative Services (BCBS)

Rehabilitative Services (UHC)

Usual and Prevailing Fee Allowance (BCBS)

Usual and Prevailing Fee Allowance (UHC)
Disability: Disability Claim Form

Post Pregnancy Maternity Short Term Disability Plan Form

Disability Enrollment Form

Disability Direct Deposit 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
Claims: Medical

Blue Cross Blue Shield Claim Form

UHC Claim Form

Dental

Dental Claim Form

Vision

EyeMed Out-of-Network Claim Form

Prescription

Prescription Reimbursement Claim Form

BCBS Medicare Part D Claim Form

UHC Medicare Part D 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

BCBS Medicare Part D Claim Form

UHC Medicare Part D Claim Form

Health Insurance Portability and Accountability Act (HIPAA)

HIPAA Authorization Form

HIPAA Complaint Form

HIPAA Policy

Medicare Crossover Enrollment

BCBS: Contact Customer Service

UHC: Medicare Crossover Enrollment Form

Medicare Part D Form

Notice of Creditable Coverage

BCBS Medicare Part D Claim Form

UHC Medicare Part D Claim Form

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

Death Benefits/Accelerated Option

Death Benefit Accelerated Claim Form
Retiree: Retirement forms can be found on Jetnet

Notices

Children's Health Insurance Program (CHIP): Children’s Health Insurance Program (CHIP)
COBRA: COBRA General Notices of Continuation of Coverage Rights
Health Insurance Marketplace: Health Insurance Marketplace Notice
Medicare Part D: Notice of Creditable Coverage

Notice of Creditable Coverage – 65 and Older

Notice of Creditable Coverage – Under 65
Women's Health & Cancer Rights Act: Women’s Health & Cancer Rights Act

Looking for another document? Check out Plan Guides or Other Forms & Notices.

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Disclaimer
This website provides an overview of your benefit options. The complete provisions of the plans are set forth in the Plan Documents and Summary Plan Description. If the information online is inconsistent with the Plan Documents, the Plan Documents will govern. This website is not intended as a contract of employment or a guarantee of current or future employment. The Plan Sponsor(s) reserve the right to amend or terminate each plan at any time.

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Privacy Policy
Your private health information is just that – private. Information gathered by our partners will be used for your benefit to help guide you on your path to wellness. These partners are required to comply with all laws protecting privacy.

What happens with my health information?
American Airlines manages employee and retiree health benefits. To assist, American Airlines has business relationships with third-party vendors, for example, BCBS, UHC, and WebMD Health Services. The sharing of health information between these companies is permitted by regulation. You may choose to share the information with your doctor and other medical professionals.