Forms for Health & Dental Services

Weight Loss Benefit Form (PDF)

Fitness Benefit Form  (PDF)

Subscriber Submission Claim Form (PDF)

Request for Outpatient Retail Pharmacy Prior Authorization (PDF)                                                                                                   This Form must be completed and submitted by the prescribing physician

Request for Retaining Coverage for a Psychologically or Physically Disabled Dependant Child (PDF)

Sample HIPPA Privacy Notice - for Accounts (PDF)

Sample HIPAA Privacy Notice - for Accounts (MS Word)