Forms & Resources

We are committed to keeping you up-to-date on all aspects of your benefit plan. Whether you need to request a new ID card for an employee or download an important form, you can find it all here.

Would you like to:

Download the Administrative Guide PDF icon

Print a form for yourself

Print a form for a member

Order an ID Card or print a temporary card for a member

Forms for Employers


PDF icon Employer Portal Access Form

COBRA Enrollment

PDF icon COBRA Qualifying Event Termination

Forms for Members


PDF icon Online Access / PHI Disclosure Form

PDF icon Member Authorization to Obtain PHI

PDF icon Member Authorization to Release PHI

PDF icon Transition of Care Request Form

Member Appeal

PDF icon Member Appeal Form

Request for Network Exception 

PDF icon Network Exception Request Form

Member Reimbursements*

PDF icon Standard Medical Claim Form

PDF icon Standard Dental Claim Form

PDF icon Member Reimbursement Form  green starsubmit your request in My Plan

PDF icon Travel Reimbursement Form  green starsubmit your request in My Plan


PDF icon Out-of-Area Dependent Coverage Verification Form


*Claim and reimbursement forms may not be applicable to all plans. Be sure to check your benefit details in your summary plan description prior to submitting a claim or reimbursement form.

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