PAI Self-Funded Forms

​Accident Questionnaire

Authorized Representative Form

Authorized Representative Form-Spanish

Benefits Enrollment / Change Form

Benefits Enrollment /Change Form-Spanish

Coordination of Benefits Form

Coordination of Benefits Form-Spanish

Dental Claim Form

Employee Termination Form

Mail Order Prescription Form (OptumRx)

Mail Order Prescription Form (OptumRx)-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