Forms for Employers and Employees

EMPLOYER
Employer Group Roster Word

EMPLOYEE:

CLAIM FORMS
Dental Claim Form PDF
Medical Claim Form PDF
CareMark Prescription Drug Claim Form PDF
HDHP Prescription Drug Claim Form PDF
Vision Claim Form PDF
Life Claim Form PDF

COBRA
COBRA Form PDF

CONTINUATION OF COVERAGE
Disabled Dependent Form PDF

DENTAL
Dental/Vision Enrollment Card Online
Dental Only Enrollment Card PDF
Dental/Vision Enrollment Card PDF
Change of Status Form Excel PDF
Refusal of Dental Coverage Word PDF
Affidavit of Domestic Partnership Form Word PDF

MEDICAL
National Health Solutions II Enrollment Form Online PDF
Texas Health Solutions II Enrollment Form PDF
HDHP Enrollment Form PDF
Idaho Universal Medical Enrollment Form PDF
CareMark Mail Order Form PDF
View a Current Drug List PDF

VISION
Enrollment Card Online PDF
Change of Status Form Excel PDF