Heath and Welfare Forms

Click the health and welfare forms below to download and print them from your computer. You will need Adobe Acrobat Reader, a free download.

Title Type Description
VISION BENEFIT IMPROVEMENTS EFFECTIVE JULY 1, 2013
DISABILITY FORM

A two-page form. First page is for member's completion and the second page is for doctor's to complete.

SUBROGATION FORM/INJURY INQUIRY

SUBROGATION FORM/INJURY INQUIRY

OPTUMRX REIMBURSEMENT FORM
FT MEDICARE RX CREDITABLE COVERAGE NOTICE.doc
HIPAA PRIVACY AUTHORIZATION FORM

AUTHORIZATION TO DISCLOSE INFORMATION TO A THIRD PARTY

EYEMED VISION CLAIM FORM FOR OUT OF NETWORK CLAIMS
COB INQUIRY FORM
2017 PT & ACA QUALIFIED BENEFIT SCHEDULES

This schedule only applies to PART  TIME & ACA QUALIFIED EMPLOYEES AS OF JANUARY 1, 2017 

THERE IS NO DEPENDENT COVERAGE INCLUDED FOR THESE BENEFITS

2017 FULL TIME BENEFIT SCHEDULE

This schedule only applies to FULL TIME EMPLOYEES AS OF JANUARY 1, 2017

HEALTH CARE REFORM INFORMATION