NHLGC Risk Services - Individual Forms

Forms

Below is a list of convenient links to download our Individual Members' most frequently requested forms.

(NOTE: You will need to have Adobe Acrobat Reader® software installed on your computer in order to download these forms as PDFs. If you don't already have it installed, simply click on our hyperlink to install a free copy.)

Address Update/Correction Form

Anthem Subscriber Claim Form

Caremark Mail Service Order Form

Caremark Prescription Drug Claim Form

Certificate of Tax Dependent Status for a Civil Union Partner*

Dental Application and Change Form*

Dental Claim Form

Dependent Child Certification Form*

Flexible Spending Account Reimbursement Form

Health Awareness Program Reimbursement Request Form

Healthcare FSA/Dependent Care Reimbursement Account Reimbursement Form

HIPAA - Authorization to Release Information to My Representative

HIPAA - Individual Request for Accounting of Disclosures

HIPAA - Individual Request to Correct or Amend a Record

HIPAA - Individual Request to Inspect Health Information

HIPAA - Individual Request Not to Use or Disclose Health Information

LGC HealthTrust Incentive Program Reimbursement Request Form

LGC Supply Order Form (Rev. 05/08)

Life, Long-term Disability (LTD), and/or Short-term Disability (STD) Application and Change Form*

Medical and/or Dental Group Application and Change Form*

Notice of Divorce, Legal Separation or Dissolution of Civil Union *

Request for Certification for a Mentally or Physically Incapacitated Dependent Child

Retirement Annuity Deduction Authorization for Medical and Dental Benefits*

Short-Term Disability Claim Form

Supplemental Disability Report - Disability Income Benefits*

*This is normally a carbonless, multi-part form but cannot be provided in that format electronically. Please check the bottom of each form page for a notation on the form's usual color-coded sections and make an appropriate number of copies to distribute accordingly once the form is completed. Thank you.