ShareThisForms and Resources
The following forms and flyers are saved as PDFs and available for you to download. Listings marked with an asterisk (*) indicate they are normally carbonless, multi-part form but cannot be provided as such electronically. Please check the bottom of each of those forms’ pages for a notation regarding their usual color-coded sections and make an appropriate number of copies to distribute accordingly once completed.
Claims
- Anthem Subscriber Claim Form
- CVS Caremark Prescription Drug Claim Form
- Dental Claim Form
- LGC HealthTrust Incentive Program Reimbursement Request Form
- Short-Term Disability Claim Form
- Supplemental Disability Report – Disability Income Benefits*
CVS Caremark Prescription Drug Program
Flexible Spending Account (FSA)
- Flexible Spending Account Direct Deposit Authorization Form
- Flexible Spending Account Supply Order Form
- FSA Reimbursement Form
Flyers
- Important Notice for Subscribers! (Open Enrollment Flyer – Medical and/or Dental)
Health Awareness Program
- Health Awareness Program Group Reimbursement Form
- Health Awareness Program Reimbursement Request Form
Life, Long-Term Disability and/or Short-Term Disability Enrollment
- Life, Long-Term Disability, and/or Short-Term Disability Application and Change Form*
- Salary Change Update Form (Life, Long-Term Disability and Short-Term Disability)
Medical and/or Dental Enrollment
- Address Update/Correction Form
- Certificate of Tax Dependent Status for a Civil Union Partner*
- Dental Application and Change Form*
- Dependent Child Certification Form*
- Medical and/or Dental Application and Change Form*
- Notice of Divorce, Legal Separation or Dissolution of Civil Union*
- Notice of Membership Changes
- Request for Certification for a Mentally or Physically Incapacitated Dependent Child
- Retirement Annuity Deduction Authorization for Medical and Dental Benefits*
Privacy and Security (HIPAA)
- HIPAA – Authorization to Release Information to My Representative
- HIPAA – Certificate of Authorizing Resolution
School Risk Management
Supply Orders