Member Forms

We have the following forms available for download in the Adobe Acrobat (PDF) format. Click on the name of the product to begin downloading. You will need Adobe's free Acrobat viewer to access these files.

Medical & Dental Claim Form
Short Term Disability Claim Form
Flexible Spending Account Reimbursement Request Form
Travel Expense Reimbursement Request Form 2007
Travel Expense Reimbursement Request Form 2008
Health Reimbursement Arrangement (HRA) Request Form

Flexible Spending Account Change in Status Form
Flexible Spending Account Over-the-Counter Drug Listing
Beneficiary Change Form
PHI Authorization Form

Pharmacy Benefit Manager (PBM) Claim Forms:
Express Scripts Claim Form
Systemed Rx (Medco) Claim Form
CVS Caremark Claim Form (formerly PharmaCare)