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 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
PT & ACA DENTAL SCHEDULE OF BENEFITS This schedule only applies to PART  TIME & ACA QUALIFIED EMPLOYEES AS OF JANUARY 1, 2014 

THERE IS NO DEPENDENT COVERAGE INCLUDED FOR THESE BENEFITS

FT & FT CLERK DENTAL SCHEDULE OF This schedule only applies to FULL TIME EMPLOYEES AND FULL TIME CLERKS AS OF JANUARY 1, 2014