Claims Forms
- Claim Appeal Form
- Designation of Authorized Representative to Appeal
- Dental Services
- Flexible Spending Account-Dependent Care
- Flexible Spending Account-Medical Reimbursement
- Health Benefits within the U.S.- Use this form only when filing a claim for services received from an out-of-network physician or health care professional.
- Health Benefits Worldwide
- Health Reimbursement Account
- Healthy Vision Out of Network
- Standard Vision Out of Network
- 2019 Prescription Drug Claim Form
- 2020 Prescription Drug Claim Form
- Mail Service Order Form
- HIPAA Authorization Form