There are a number of forms you need on a regular basis to manage your benefits. These forms can be downloaded and printed using Adobe Acrobat® software. If Acrobat® is already installed on your machine, you can click on any one of the links below to immediately access the form.

Forms & Document Library

Brand Exception PDF | 16 kb: Brand Exception Request Form

COB PDF | 350 kb: COB Form

Dental Claim PDF | 274 kb: ADA Dental Claim Form

Dentist Nomination PDF | 304 kb: Dentist Nomination Form

Doctor Nomination PDF | 564 kb: Physican Nomination Form

HRA Direct Deposit PDF | 61 kb: HRA Direct Deposit Form

HRA Reimbursement PDF | 77 kb: HRA Reimbursement Form

HSA Authorization: HSA Authorization/Enrollment Form

Lab Reminder PDF | 1 mb: Lab Savings Program Reminder Card Form

Medical Claim PDF | 218 kb: Medical Claim Form

Part B Pilot Direct Deposit Form PDF | 54 kb: Medicare Part B Pilot Direct Deposit Form

Part B Pilot Enrollment Form PDF | 54 kb: Medicare Part B Pilot Enrollment Form

Part B Pilot Reimbursement Request Form PDF | 55 kb: Medicare Part B Pilot Premium Reimbursement Request Form

Newly Eligible Dependent Enrollment Form PDF | 150 kb: Use to add or reinstate dependents under age 26

Overseas Claim PDF | 1.5 mb: Overseas Medical Claim Form

Pharmacy Claim PDF | 80 kb: Pharmacy Claim Form

Caremark Mail Order PDF | 100 kb: Caremark Mail Order Service Form

Travel Form PDF | 240 kb: Travel Reimbursement Request

Adobe Reader: To view and print PDF files, download and install the latest version of Adobe Reader.

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