Forms & Document Library

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There are a number of forms and documents that can help you 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
Medical Loss Ratio Notice
PDF | 42 kb
Medical Loss Ratio Information
MHBP Notice of Privacy Practices
PDF | 140 kb
MHBP's policy and practices related to your protected health information
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
Part B Premium Savings Program Direct Deposit Form
PDF | 54 kb
Part B Premium Savings Program Direct Deposit Form
Part B Premium Savings Program Enrollment Form
PDF | 54 kb
Part B Premium Savings Program Enrollment Form
Part B Premium Savings Program Reimbursement Form
PDF | 55 kb
Part B Premium Savings Program Reimbursement Form
Prescription Drug Claim - Retail Pharmacy
PDF | 80 kb
Prescription Drug Claim form for prescriptions obtained from a retail pharmacy
Prescription Drug Claim - Mail Order
PDF | 100 kb
Caremark Mail Order Service Claim Form
SBC Glossary
PDF | 90 kb
Summary of Benefits and Coverage Glossary
SBC Consumer Option
PDF | 260 kb
Consumer Option Summary of Benefits and Coverage
SBC Standard Option
PDF | 261 kb
Standard Option Summary of Benefits and Coverage
SBC Value Plan
PDF | 260 kb
Value Plan Summary of Benefits and Coverage
Transplant-related Travel
PDF | 240 kb
Travel Reimbursement Request - Coventry Transplant Network only
FEHB Urine Drug Testing Notice
PDF | 42 kb
FEHBP Urine Drug Testing Coverage

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