Member Forms
Balance Billing Notice
Your rights and protections against surprise medical bills.
COBRA Administration Form
This form is used to provide information about other coverage a COBRA participant may have to assure coordination of payments.
Debit
Card Pin Number
This is a set of instructions for obtaining a Debit Card Pin Number.
Dental
Claim Form
This form is used to submit claims for dental expenses under a dental plan.
Designation of Personal Representative
This form must be provided when a covered employee or dependent wishes to designate an authorized personal representative to have access to their claim information and other personal health data.
Disability
Claim Form
This form is used to submit claims for income replacement under a short term disability plan.
EOB Sample
This is a sample Explanation of Benefits form.
Flexible Spending
Account Claim Form
This form is used to submit claims for medical expenses under a health care flexible spending arrangement and dependent care expenses under a dependent care flexible spending arrangement.
Health Reimbursement Arrangement (HRA) Claim Form
This form is used to submit claims for expenses under a health reimbursement arrangement.
Medical Claim Form
This form is used to verify employee eligibility for group health plan coverage. This form may also be used
to submit a group health plan claim, however claim forms are not required.
Request for Duplicate Coverage
This form is required at least once per year to verify if dependents have other coverage.
SBC Uniform Glossary
This is a uniform glossary of terms commonly used in health insurance coverage.
Code Sect 213(d) Eligible Expenses
This is a listing of common IRS Section 213(d) eligible reimbursable expenses.
Supplemental
Accident Questionnaire
This form is required for claims related to an accident.
Vision Claims Form
This form is used to submit claims for vision related expenses under a vision plan.
