Healthcare Forms

Claim reimbursement forms and other health care documents are in the Adobe PDF format. Click the graphic on the right to download the latest version of Adobe Reader. Some forms may require Microsoft Office applications.

• CLAIM AND HIPAA AUTHORIZATION FORMS

  Accident Detail Form	PDF
  Other Insurance Verification Form	PDF
  HIPAA Authorization Form	PDF
  Sample Notice of Privacy Practices	PDF

• FLEXIBLE SPENDING ACCOUNT (FSA) FORMS

  Health Care Reimbursement Form	PDF
  Dependent Care Reimbursement Form	PDF
  Transportation and Parking Reimbursement Form	PDF
  HRA Reimbursement Form	PDF

• EMPLOYEE NOTICES

  Employee Notices Packet (Small Group, Medicare Part D Creditable)	PDF
  Employee Notices Packet (Small Group, Medicare Part D Creditable, IL ERISA)	PDF
  Employee Notices Packet (Large Group, Medicare Part D Creditable)	PDF
  Employee Notices Packet (Large Group, Medicare Part D Creditable, IL ERISA)	PDF
  Employee Notices Packet (Small Group, Medicare Part D Non-Creditable)	PDF

• MISCELLANEOUS FORMS

  Caremark Mail Service Order Form	PDF
  Specialty Pharmacy Request Form	PDF
  Dependent Coverage Notification Card	PDF
  Women’s Health and Cancer Rights Act Sample Notification	Microsoft Word
  CMS Information – Member Refusal to Provide SSN to Medicare	PDF
  HIPAA BA Amendment – HITECH	Microsoft Word
  PPACA Plan Amendment - IL Government Clients (School Districts\Municipalities)	PDF
  PPACA Plan Amendmnet - Non IL	PDF

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