With the right information, you can make more responsible, financial healthcare decisions. We want you to be able to take control of your own healthcare with access to our resources and comprehensive toolkit of forms. MEDICAL, DENTAL AND VISION CLAIM FORMS Claim Form - Medical Claim Form - Dental Claim Form - Vision Claims Fax Cover Sheet FLEXIBLE SPENDING ACCOUNT REIMBURSEMENT (FSA) Flex Direct Deposit Form Flex Reimbursement Request Form PARTICIPANT (INDIVIDUAL & FAMILY) PLAN FORMS Accident Coordination of Benefits Questionaire Third Party Liability Form EXCHANGE MODEL NOTICES & RIGHTS NOTIFICATION Exchange Model Notice (Coverage Provided) Exchange Model Notice (No Coverage Provided) Exchange Model Notice Sample Cover Letter Women's Cancer Rights Notification Children's Health Insurance Program (CHIP) Notice MEDICARE DOCUMENTS & INFORMATION Employee Notice Packet (Medicare Part D Creditable) Employee Notice Packet (Medicare Part D Non-Creditable) PROVIDER PRE-AUTHORIZATION FORMS Retail Pharmacy Prior Authorization Request Form Specialty Pharmacy Medical Request Formulary Exclusion Prior Authorization Form Healthcare Authorization Form SECURITY/PRIVACY FORMS & DOCUMENTS HIPAA Authorization Form Notice of Privacy Practice MISCELLANEOUS Summary of Benefits and Coverage Uniform Glossary IMPORTANT NOTICES Your Rights and Protections Against Surprise Medical Bills Extended Plan Deadlines