Forms and Resources
The following forms and resources are saved as PDFs and available to download. Listings marked with an asterisk (*) indicate they are normally carbonless, multi-part forms but cannot be provided as such electronically. Please check the bottom of each of those forms’ pages for a notation regarding their usual color-coded sections and make an appropriate number of copies to distribute accordingly once completed.
View the following list of forms alphabetically.
Claims
- Anthem Subscriber Claim Form
- CVS Caremark Prescription Drug Claim Form
- Dental Claim Form
- LGC HealthTrust Incentive Program Reimbursement Request Form
CVS Caremark Prescription Drug Program
Flexible Spending Account (FSA)
- Flexible Spending Account Direct Deposit Authorization Form
- FSA Reimbursement Form
- Healthcare FSA List of Eligible/Ineligible Expenses
Life, Long-Term Disability and/or Short-Term Disability
Enrollment Forms
Medical and/or Dental Enrollment
- Address Update/Correction Form
- Certificate of Tax Dependent Status for a Civil Union Partner*
- Dental Application and Change Form*
- Dependent Child Certification Form*
- Medical and/or Dental Application and Change Form*
- Notice of Divorce, Legal Separation or Dissolution of Civil Union*
- Request for Certification for a Mentally or Physically Incapacitated Dependent Child
- Retirement Annuity Deduction Authorization for Medical and Dental Benefits*
Privacy and Security Forms (HIPAA)
- HIPAA – Authorization to Release Information to My Representative
- HIPAA – Individual Request for Accounting for Disclosures
- HIPAA – Individual Request to Correct or Amend a Record
- HIPAA – Individual Request to Inspect Health Information
- HIPAA – Individual Request Not to Use or Disclose Health Information
Slice of Life
- Biometric Health Screening Form
- Health Awareness Program Group Reimbursement Form
- Health Awareness Program Reimbursement Request Form (2011)
- Health Awareness Program Request Form (2012)