Types of forms
- Dental claim form
- Health claim form
Use this form to submit medical charges for benefits that were not filed by the physician or healthcare professional. There are step-by-step instructions on how to file charges on the reverse side of the claim form.
- Prescription claim form
- Prescription claim form - Spanish
- Vision claim form
If you choose to see an out-of-network provider, submit your itemized receipt(s) along with the out-of-network reimbursement form. You will be reimbursed the allotted amount based on your benefits.
- Change request form
This form is used to make changes to a currently enrolled employee's address, name and telephone number or to cancel coverage for an employee and/or dependent(s).
- Explanation of payment form
- Proof of incapacity of a dependent - Physician's form
- Proof of incapacity of a dependent - Policyholder's form
- Reinstatement form
- State of AR continuation of coverage election
- Request for continuity of care
Group samples of non-metallic certificates:
- Sample HSA grandfathered
- Sample HSA non grandfathered
- Sample PPO grandfathered
- Sample PPO non grandfathered