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Home > Forms > Health Forms
HEALTH FORMS
Some plans do not include every benefit mentioned. Refer to your plan booklet to verify which benefits are included in your
plan.
2008 Plan D5 Open Enrollment Election and Payroll Deduction Authorization Form
2008 Plan B5 Open Enrollment Election and Payroll Deduction Authorization Form
Health Claim Form
Dental Claim Form
Vision Claim Form
Continuing Income Protection Claim Form
Authorization for Release of Personal Health Information (for
all Plans except Plan B5)
Autorización para la divulgación de información médica personal
Authorization for Release of Personal Health Information (for
Plan B5)
Dependent Registration Form (for Plan D5 Family Coverage)
Application for Plan M
Authorization Agreement for Electronic Transfer of Payments for Plan M
Authorization Agreement for Electronic Transfer of Payments for COBRA
Dental Schedule of Benefits
Health Plan Document
Notice of Prescription Drug Creditable Coverage under Medicare
Notice of Prescription Drug Coverage (Plan Classification D5–Tier B)
that is Not Creditable Coverage under Medicare
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