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CLAIMS FORMS

Dental Claim Form
Reimbursement Form
Authorization Request Form for Providers
Authorization to Release Information
Rx Claim Form
HIPAA Privacy Act Authorization
Rights and Protections Against Surprise Medical Bills

COBRA FORMS

COBRA Continuation Coverage Election Notice

FSA

FSA & HRA Eligible & Ineligible Items

Claim Form

Plan Summary

The Clear Card Request Form

Enrollment Form With Premiums

Enrollment Form Without Premiums

General & Limited Enrollment Form

Revolving Dependent Care Form

$500 Roll Over Flyer

Tax Savings Flyer

Dependent Care Only Enrollment Form

Direct Deposit Form - Employee

HIPAA Authorization Form - Employee

HIPAA Form

HRA Claim Form

Premium Only Enrollment Form

STOP LOSS

Work Eligibility Status Form

Other Coverage Information

PRODUCT UPDATES

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Possibly, the greatest reason why we are able to bring you clarity in this ever shifting healthcare industry, is because of the extraordinary array of services our team brings you and our unmatched ability to methodically and responsibly manage your very own self-funded healthcare plan.