Member Forms

Everything you need all in one place.

Member Forms

Get the forms and resources you need for things like Enrollment, HRA/FSA reimbursement, Prior Authorization and more. You can easily find and download what you need to make sure your account stays up to date.

Appeal Request Form

If you need to appeal a denied benefits request, use this form to start the process.

Download

Enrollment Application

Use this form to enroll in a benefits package.

Download

FSA Enrollment Application

Need to enroll in a Flexible Spending Account? Use this form to do so

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FSA Reimbursement Form

If you have a Flexible Spending Account, use this form to submit your expenses to be reimbursed.

Download

FSA Dependent Care Reimbursement Form

If you have a Flexible Spending Account, use this form to submit your dependent care expenses to be reimbursed.

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HRA Reimbursement Form

Complete this form to receive funds from your Healthcare Reimbursement Agreement account to cover healthcare costs

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PHI Release / Designation of Person Form

Complete the form to allow your provider or other party to release your health information.

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Status Change Form

If you’ve had a life change event, use this form to update your status, add or remove dependents, and more.

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Student Verification Form

If one of your dependents is a student over the age of 18, use this form to verify their dependent eligibility.

Download

Request for Appointment of Personal Representative Form

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Rights and Protections

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

Download

Contact Us

We’re here to answer your questions and get you the information you need. Contact us using the number found on the back of your ID card.

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