Forms

Please choose a form below to download.

Statement of Claim Form / Medical Claim Form

To submit the Statement of Claim / Medical Claim Form you can download the form from this link and submit the completed claim form to the address provided on your ID card. You must complete and sign a Statement of Claim form at least once each year.

Dental Claim Form

To submit a dental claim for processing you can download a Dental Claim Form from this link and submit completed claim form to the address provided on your ID card.

Appeals and Grievances Form

This is the Appeals and Grievances Form.

Subrogation Form

If you have incurred expenses that the Administrator deems could have been the result of Acts of Third Parties you may be requested to complete the Subrogation Form. You can download the form from this link and submit the completed signed form to the address provided on your ID card.

Optum-RX Prescription Reimbursement Request Form

To submit the Prescription Reimbursement form you can download the form from this link and submit the completed form to the address listed on the form. You will need to attach your receipts to the form where indicated.

Enrollment Form

A completed enrollment card must be on file with the Plan in order to allow the processing of claims. You can download the Enrollment Form from this link and submit to the address provided on your ID card.

Personal Care Account Claim Form

To submit the Personal Care Account Claim Form you can download the form from this link and submit the completed claim form to the address provided on the form.

Short Term Disability Form

This is the Short Term Disability Form.

Short Term Disability Certification Form

This is the Short Term Disability Certification Form.