General Forms

Summary of Benefits and Coverage
This document describes what the plan covers and what it costs.

Glossary of Health Coverage and Medical Terms

Medical and Dental Plan Document
This is the Summary Plan Description of your medical and dental plan.

Amendment to the Medical and Plan Document

Protected Health Information Authorization
Use this form to let us know if you want to allow someone other than yourself to discuss your health information.  This could be your wife or husband, a relative, an attorney and so on.

Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

Qualified Medical Child Support Order
This document contains information regarding medical child support orders.

Other Health/Dental Coverage Questionnaire
To provide information about possible other coverage.

Prescription Drug Forms

MEDTRAK pharmacy plan.....Call 800-771-4648 for information and assistance

Self Funded Forms

Self Funded EOB Guide
Use this form as a guide to read your Explanation of Benefits for claims.

Self Funded Accident Form
Use this form to let us know if health care was the result of an accident.

Subrogation Form
Use this form to let us know if you will be getting a settlement payment for an accident from another person or business.  This form lets us know that we will be reimbursed for any treatment we have paid for due to that accident.

Self Funded Yearly Claim Form
Use this form to let us know if there have been any changes that would affect your insurance, such as a spouse getting or losing coverage under other insurance, or if a child has become or is no longer a full time student.

Claims Transmittal Form
Use this form to file a claim with medical bills and Prescription Drug receipts.

Flexible Spending Account (FSA) Forms

FSA Claim Form
Use this form to send claims to us for your Flexible Spending Account.

FSA Qualified Expenses
Use this form to determine if health expenses are covered under your Flexible Spending Account.

FSA Child Care Qualifying Expenses
Use this form to determine if expenses for your child's care are covered under your Flexible Spending

FSA Enrollment Form
Use this form if your employer offers a Flexible Spending Account and you need to indicate if you will or
will not be participating.

Miscellaneous Forms & Documents

Medical and Prescription Drug Definitions

Reasons Medical Claims Denied
This document explains the top reasons why a medical claim could be denied.

Medicaid/Chip Notice
Medicaid and the Children’s Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families.

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BENEFITS website
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