Forms

Administrative Services

Accident Questionnaire

Accident Questionnaire-Spanish

Authorization to Disclose PHI to a Third Party

Authorized Representative Form

Authorized Representative Form - Spanish

Benefits Enrollment/Change Form

Benefits Enrollment/Change Form-Spanish

Continuation of Care Form

Coordination of Benefits Form

Coordination of Benefits Form-Spanish

Dental Claim Form

Employee Termination Form

Mail Order Prescription Form (Optum Rx)

Mail Order Prescription Form (Optum Rx)-Spanish

Medical Benefits Short-Term Disability Claim Form

Medical Benefits Short-Term Disability Claim Form-Spanish

Medical Claim Form

Medical Claim Form-Spanish

Prescription Reimbursement Request Form

Short-Term Disability Claim Form

Short-Term Disability Claim Form-Spanish

Level Funding

Level Funded Automated Risk Assessment

Level Funded EE 51+ EE App

​

​

Indemnity Plan

Authorized Representative Form - English

Authorized Representative Form – Spanish

Dental Claim Form - English

Dental Claim Form – Spanish

Medical Claim Form - English

Medical Claim Form-Spanish

Missed Premium Direct Payment Form - English

Missed Premium Direct Payment Form-Spanish

Prescription Drug Reimbursement Claim Form - English 

Prescription Drug Reimbursement Claim Form-Spanish 

Short-Term Disability / Proof of Loss Claim Form - English

Short-Term Disability /Proof of Loss Claim Form – Spanish 

Term Life / Accidental Death and Dismemberment - English

Vision Claim Form - English

EyeMed Out of Network Vision Services Claim Form  - English

EyeMed Out of Network Vision Services Claim Form-Spanish

MEC Plan

MEC Medical Claim Form - English

MEC Medical Claim Form-Spanish

MEC Missed Contribution Direct Payment Form Weekly - English

MEC Prescription Drug Reimbursement Claim Form - English

MVP

MVP Coordination of Benefits Form - English

​

Indemnity Plan

Authorized Representative Form - English

Authorized Representative Form – Spanish

Dental Claim Form - English

Dental Claim Form – Spanish

Medical Claim Form - English 

Medical Claim Form-Spanish

Missed Premium Direct Payment Form - English

Missed Premium Direct Payment Form-Spanish

Prescription Drug Reimbursement Claim Form - English 

Prescription Drug Reimbursement Claim Form-Spanish 

Short-Term Disability / Proof of Loss Claim Form - English

Short-Term Disability /Proof of Loss Claim Form – Spanish 

Term Life / Accidental Death and Dismemberment - English

Vision Claim Form - English

EyeMed Out of Network Vision Services Claim Form - English

EyeMed Out of Network Vision Services Claim Form-Spanish

MEC Plan

MEC Missed Contribution Direct Payment Form Weekly - English

MEC Medical Claim Form - English

MEC Medical Claim Form-Spanish

MEC Missed Contribution Direct Payment Form Weekly - English

MEC Prescription Drug Reimbursement Claim Form - English

MVP

MVP Coordination of Benefits Form - English

Indemnity Plan

Accidental Death & Dismemberment Claim Form - English

Accidental Death Dismemberment Claim Form-Spanish

Accidental Dismemberment -Physician Statement - English

Accidental Dismemberment -Physician Statement-Spanish

Accidental Loss of Life, Limb or Sight Claim Form - English

Accidental Loss of Life, Limb or Sight Claim Form-Spanish

Accidental Loss of Limb or Sight - Physician Statement - English

Accidental Loss of Limb or Sight - Physician Statement- Spanish

Accidental Indemnity and Critical Illness Claim Form - English

Authorized Representative Form - English

Authorized Representative Form-Spanish

Dental Claim Form - English

Dental Claim Form-Spanish

EyeMed Out of Network Vision Services Claim Form - English

EyeMed Out of Network Vision Services Claim Form-Spanish

Medical Claim Form - English

Medical Claim Form-Spanish

Missed Premium Direct Payment Form - English

Missed Premium Direct Payment Form-Spanish

Prescription Drug Reimbursement Claim Form - English (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)

Prescription Drug Reimbursement Claim Form-Spanish (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)

Prescription Drug Reimbursement Request Form (Optum Rx) - English (Use this form if Rx group BXPAI is on your ID card. If you medical plan entitles you to pay a co-pay at the point of purchase and your prescription was not filed directly to OptumRx by the pharmacy, use this form to submit payment. If your medical plan entitles you to a discount at the point of purchase, and you file your receipts to PAI for reimbursement, please use the form above.)

Short-Term Disability / Proof of Loss Claim Form - English

Short-Term Disability / Proof of Loss Form-Spanish

Term Life Claim Form - English

Term Life Life Claim Form-Spanish

Termination / Loss of Coverage Form - English

Termination / Loss of Coverage Form-Spanish

ESC5500 Plan

ESC5500 Coordination of Benefits - English

MEC Plans

MEC Medical Claim Form - English

MEC Medical Claim Form-Spanish

MEC Missed Contribution Direct Payment Form-for MEC Weekly Plans - English

MEC Prescription Drug Reimbursement Claim Form - English

Indemnity Plan

Accidental Death & Dismemberment Claim Form - English

Accidental Death Dismemberment Claim Form-Spanish

Accidental Dismemberment -Physician Statement - English

Accidental Dismemberment -Physician Statement-Spanish

Accidental Loss of Life, Limb or Sight Claim Form - English

Accidental Loss of Life, Limb or Sight Claim Form-Spanish

Accidental Loss of Limb or Sight - Physician Statement - English

Accidental Loss of Limb or Sight - Physician Statement- Spanish

Accidental Indemnity and Critical Illness Claim Form - English

Authorized Representative Form - English

Authorized Representative Form-Spanish

Dental Claim Form - English

Dental Claim Form-Spanish

EyeMed Out of Network Vision Services Claim Form - English

EyeMed Out of Network Vision Services Claim Form-Spanish

Medical Claim Form - English

Medical Claim Form-Spanish

Missed Premium Direct Payment Form - English

Missed Premium Direct Payment Form-Spanish

Prescription Drug Reimbursement Claim Form - English (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)

Prescription Drug Reimbursement Claim Form-Spanish (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)

Prescription Drug Reimbursement Request Form (Optum Rx) - English (Use this form if Rx group BXPAI is on your ID card. If you medical plan entitles you to pay a co-pay at the point of purchase and your prescription was not filed directly to OptumRx by the pharmacy, use this form to submit payment. If your medical plan entitles you to a discount at the point of purchase, and you file your receipts to PAI for reimbursement, please use the form above.)

Short-Term Disability / Proof of Loss Claim Form - English

Short-Term Disability / Proof of Loss Form-Spanish

Term Life Claim Form - English

Term Life Life Claim Form-Spanish

Termination / Loss of Coverage Form - English

Termination / Loss of Coverage Form-Spanish

ESC5500 Plan

ESC5500 Coordination of Benefits - English

MEC Plans

MEC Medical Claim Form - English

MEC Medical Claim Form-Spanish

MEC Missed Contribution Direct Payment Form-for MEC Weekly Plans - English

MEC Prescription Drug Reimbursement Claim Form - English

Indemnity Plan

Accidental Death & Dismemberment Claim Form - English

Accidental Death Dismemberment Claim Form-Spanish

Accidental Dismemberment -Physician Statement - English

Accidental Dismemberment -Physician Statement-Spanish

Accidental Loss of Life, Limb or Sight Claim Form - English

Accidental Loss of Life, Limb or Sight Claim Form-Spanish

Accidental Loss of Limb or Sight - Physician Statement - English

Accidental Loss of Limb or Sight - Physician Statement- Spanish

Accidental Indemnity and Critical Illness Claim Form - English

Authorized Representative Form - English

Authorized Representative Form-Spanish

Dental Claim Form - English

Dental Claim Form-Spanish

EyeMed Out of Network Vision Services Claim Form - English 

EyeMed Out of Network Vision Services Claim Form-Spanish 

Medical Claim Form - English

Medical Claim Form-Spanish

Missed Premium Direct Payment Form - English

Missed Premium Direct Payment Form-Spanish

Prescription Drug Reimbursement Claim Form - English (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)

Prescription Drug Reimbursement Claim Form-Spanish (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)

Prescription Drug Reimbursement Request Form (Optum Rx) - English (Use this form if Rx group BXPAI is on your ID card. If you medical plan entitles you to pay a co-pay at the point of purchase and your prescription was not filed directly to OptumRx by the pharmacy, use this form to submit payment. If your medical plan entitles you to a discount at the point of purchase, and you file your receipts to PAI for reimbursement, please use the form above.)

Short-Term Disability / Proof of Loss Claim Form - English

Short-Term Disability / Proof of Loss Form-Spanish

Term Life Claim Form - English

Term Life Life Claim Form-Spanish

Termination / Loss of Coverage Form - English

Termination / Loss of Coverage Form-Spanish

MEC Plans

MEC Medical Claim Form - English

MEC Medical Claim Form-Spanish

MEC Missed Contribution Direct Payment Form-for MEC Weekly Plan - English

MEC Prescription Drug Reimbursement Claim Form - English

Indemnity Plan

Accidental Death & Dismemberment Claim Form - English

Accidental Death Dismemberment Claim Form-Spanish

Accidental Dismemberment -Physician Statement - English

Accidental Dismemberment -Physician Statement-Spanish

Accidental Loss of Life, Limb or Sight Claim Form - English

Accidental Loss of Life, Limb or Sight Claim Form-Spanish

Accidental Loss of Limb or Sight - Physician Statement - English

Accidental Loss of Limb or Sight - Physician Statement- Spanish

Accidental Indemnity and Critical Illness Claim Form - English

Authorized Representative Form - English

Authorized Representative Form-Spanish

Dental Claim Form - English

Dental Claim Form-Spanish

EyeMed Out of Network Vision Services Claim Form - English 

EyeMed Out of Network Vision Services Claim Form-Spanish 

Medical Claim Form - English

Medical Claim Form-Spanish

Missed Premium Direct Payment Form - English

Missed Premium Direct Payment Form-Spanish

Prescription Drug Reimbursement Claim Form - English (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)

Prescription Drug Reimbursement Claim Form-Spanish (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)

Prescription Drug Reimbursement Request Form (Optum Rx) - English (Use this form if Rx group BXPAI is on your ID card. If you medical plan entitles you to pay a co-pay at the point of purchase and your prescription was not filed directly to OptumRx by the pharmacy, use this form to submit payment. If your medical plan entitles you to a discount at the point of purchase, and you file your receipts to PAI for reimbursement, please use the form above.)

Short-Term Disability / Proof of Loss Claim Form - English

Short-Term Disability / Proof of Loss Form-Spanish

Term Life Claim Form - English

Term Life Life Claim Form-Spanish

Termination / Loss of Coverage Form - English

Termination / Loss of Coverage Form-Spanish

MEC Plans

MEC Medical Claim Form - English

MEC Medical Claim Form-Spanish

MEC Missed Contribution Direct Payment Form-for MEC Weekly Plans - English

MEC Prescription Drug Reimbursement Claim Form - English

Indemnity Plan

Accidental Death & Dismemberment Claim Form - English

Accidental Death & Dismemberment Claim Form-Spanish

Accidental Dismemberment Claim Form (Physician's Statement) - English

Accidental Dismemberment Claim Form (Physician's Statement)-Spanish

Accidental Loss of Life, Limb or Sight Form - English

Accidental Loss of Life, Limb or Sight Claim Form-Spanish

Accidental Loss of Limb or Sight Claim Form-Physician's Statement - English

Accidental Loss of Limb or Sight Claim Form-Physician's Statement-Spanish

Authorized Representative Form - English

Authorized Representative Form-Spanish

Dental Claim Form - English

Dental Claim Form-Spanish

EyeMed Out of Network Vision Services Claim Form - English 

EyeMed Out of Network Vision Services Claim Form-Spanish 

Medical Claim Form - English

Medical Claim Form-Spanish

Missed Premium Direct Payment Form

Missed Premium Direct Payment Form-Spanish

Prescription Drug Reimbursement Claim Form - English (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)

Prescription Drug Reimbursement Claim Form-Spanish (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)

Prescription Drug Reimbursement Request Form (OptumRx) - English (Use this form if Rx group BXPAI is on your ID card. If you medical plan entitles you to pay a co-pay at the point of purchase and your prescription was not filed directly to OptumRx by the pharmacy, use this form to submit payment. If your medical plan entitles you to a discount at the point of purchase, and you file your receipts to PAI for reimbursement, please use the form above.)

Short-Term Disability / Proof of Loss Claim Form - English

Short-Term Disability / Proof of Loss Claim Form-Spanish

Term Life Claim Form - English

Term Life Claim Form-Spanish

Termination / Loss of Coverage Form - English

Termination / Loss of Coverage Form-Spanish

MEC Plan

MEC Medical Claim Form - English

MEC Medical Claim Form-Spanish

MEC Missed Premium Direct Payment Form - English

MEC Prescription Drug Reimbursement Claim Form - English

Indemnity Claim Forms

Accidental Death & Dismemberment Claim Form - English

Accidental Death & Dismemberment Claim Form-Spanish

Accidental Dismemberment Claim Form (Attending Physician's Statement) - English

Accidental Dismemberment Claim Form (Attending Physician's Statement)-Spanish

Accidental Loss of Life, Limb or Sight Claim Form - English

Accidental Loss of Life, Limb or Sight Claim Form-Spanish

Accidental Loss of Limb or Sight Claim Form (Attending Physician's Statement) - English

Accidental Loss of Limb or Sight Claim Form (Attending Physician's Statement)-Spanish

Authorized Representative Form - English

Authorized Representative Form-Spanish

Dental Claim Form - English

Dental Claim Form-Spanish

EyeMed Out of Network Vision Services Claim Form - English 

EyeMed Out of Network Vision Services Claim Form-Spanish 

Medical Claim Form - English

Medical Claim Form-Spanish

Missed Premium Direct Payment Form - English

Missed Premium Direct Payment Form-Spanish

Prescription Drug Reimbursement Claim Form - English (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)

Prescription Drug Reimbursement Claim Form-Spanish (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)

Prescription Drug Reimbursement Request Form (OptumRx) - English (Use this form if Rx group BXPAI is on your ID card. If you medical plan entitles you to pay a co-pay at the point of purchase and your prescription was not filed directly to OptumRx by the pharmacy, use this form to submit payment. If your medical plan entitles you to a discount at the point of purchase, and you file your receipts to PAI for reimbursement, please use the form above.)

Short-Term Disability / Proof of Loss Claim Form - English

Short-Term Disability / Proof of Loss Claim Form-Spanish

Term Life Claim Form - English

Term Life Claim Form-Spanish

Termination / Loss of Coverage Form - English

Termination / Loss of Coverage Form-Spanish

MEC Plan

MEC Medical Claim Form - English

MEC Medical Claim Form-Spanish

MEC Missed Premium Direct Payment Form - English

MEC Prescription Drug Reimbursement Claim Form - English

​

Dental Claim Form - English

Dental Claim Form-Spanish

EyeMed Out-of-Network Claim Form - English

Medical Claim Form - English

Medical Claim Form-Spanish

Missed Premium Direct Payment Form - English

Missed Premium Direct Payment Form-Spanish

Prescription Drug Reimbursement Claim Form - English (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)

Prescription Drug Reimbursement Claim Form-Spanish (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)

Prescription Drug Reimbursement Request Form (OptumRx) - English (Use this form if Rx group BXPAI is on your ID card. If you medical plan entitles you to pay a co-pay at the point of purchase and your prescription was not filed directly to OptumRx by the pharmacy, use this form to submit payment. If your medical plan entitles you to a discount at the point of purchase, and you file your receipts to PAI for reimbursement, please use the form above.)

Short-Term Disability / Proof of Loss Claim Form - English

Short-Term Disability / Proof of Loss Claim Form-Spanish

Term Life / Accidental Death Claim Form - English

Term Life / Accidental Death Claim Form-Spanish

​

Indemnity Plan

Authorized Representative Form - English

Authorized Representative Form – Spanish

Dental Claim Form - English

Dental Claim Form – Spanish

EyeMed Out of Network Vision Services Claim Form - English 

EyeMed Out of Network Vision Services Claim Form-Spanish 

Medical Claim Form - English

Medical Claim Form-Spanish

Missed Premium Direct Payment Form - English

Missed Premium Direct Payment Form-Spanish

Prescription Drug Reimbursement Claim Form - English (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)

Prescription Drug Reimbursement Claim Form-Spanish (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)

Short-Term Disability / Proof of Loss Claim Form - English

Short-Term Disability /Proof of Loss Claim Form – Spanish 

Term Life / Accidental Death and Dismemberment - English

MEC Plan

MEC Medical Claim Form - English

MEC Medical Claim Form-Spanish

MEC Missed Contribution Direct Payment  - English

MEC Prescription Drug Reimbursement Claim Form - English

Indemnity Plan

Accidental Death & Dismemberment Claim Form - English

Accidental Death & Dismemberment Claim Form-Spanish

Accidental Dismemberment Claim Form (Attending Physician's Statement - English)

Accidental Dismemberment Claim Form (Attending Physician's Statement)-Spanish

Accidental Loss of Life, Limb or Sight Claim Form - English

Accidental Loss of Limb or Sight Claim Form-Spanish

Accidental Loss of Limb or Sight Claim Form (Attending Physician's Statement) - English

Accidental Loss of Limb or Sight Claim Form (Attending Physician's Statement)-Spanish

Dental Claim Form - English

Dental Claim Form-Spanish

Eye Exam Claim Form - English

Medical Claim Form - English

Medical Claim Form-Spanish

Missed Premium Direct Payment Form - English

Missed Premium Direct Payment Form-Spanish

Prescription Drug Reimbursement Claim Form - English (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)

Prescription Drug Reimbursement Claim Form - Spanish (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)

Prescription Drug Reimbursement Request Form (OptumRx) - English (Use this form if Rx group BXPAI is on your ID card. If you medical plan entitles you to pay a co-pay at the point of purchase and your prescription was not filed directly to OptumRx by the pharmacy, use this form to submit payment. If your medical plan entitles you to a discount at the point of purchase, and you file your receipts to PAI for reimbursement, please use the form above.)

Short-Term Disability / Proof of Loss Claim Form - English

Short-Term Disability / Proof of Loss Claim Form-Spanish

Term Life Claim Form - English

Term Life Claim Form-Spanish

Term Life / Accidental Death Claim Form - English

Term Life-Accidental Death Claim Form-Spanish

Termination / Involuntary Loss of Coverage Form - English

Termination / Involuntary Loss of Coverage Form-Spanish

Vision Out of Network Claim Form - English

Vision Out of Network Claim Form-Spanish

MEC Plan

MEC Medical Claim Form

MEC Medical Claim Form-Spanish

MEC Missed Premium Direct Payment Form - English

MEC Prescription Drug Reimbursement Claim Form - English

Access Request Form

Amendment Request Form

Authorization for Marketing (Health Plan)

Authorization to Disclose PHI to a Third Party

Complaint Form

Confidential Communication Request

Designation of Authorized Representative to Appeal

Disclosure Accounting Accounting Request

Notice of Privacy Practices-PAI

Notice of Privacy Practices-PAI (Spanish)

Restriction Request

MEC Medical Claim Form - English

MEC Medical Claim Form-Spanish

MEC Missed Premium Direct Payment Form - English

MEC Missed Premium Direct Payment Form-Spanish

MEC Wellness and Preventive Reimbursement Claim Form - English