Skip Navigation Skip to Footer Links

Forms

A Special Note On Forms

We’ve updated the forms area. As a result, some forms have been updated, some removed, and some have been moved to Benefits Connection. Be sure to use the most current forms.

Authorization Form for Release of Health and Payment Information

Authorization Form Granting Access to PHI - Insured Clients

Authorization Form Granting Access to PHI - Self Funded Clients

Certification of Handicapped Child's Dependency Status

Change Transmittal Form

COBRA Application

Coordination of Benefits Form

Dentist Change of Address Form

EFT Enrollment Form

Eligibility Enrollment Change Form

Employer Eligibility Submissions Password Request Form

NPI Form

Oral Health Enhancement Option Qualification Form

Request for External Review (Appeal Form 1B)

Request for Internal Review (Appeal Form 1A)

Student Documentation Verification Form

W-9

*The claim form has been moved to Benefits Connection.

 

Site Updates