Authorization Form Granting Access to PHI - Insured Clients (PDF, 3 pages, 52kb)
Authorization Form Granting Access to PHI - Self Funded Clients (PDF, 3 pages, 51kb)
Eligibility Enrollment Change Form (PDF, 2 pages, 22kb)
Use this form to submit new adds, changes, and terminations.
COBRA Application (PDF, 1 page, 63kb)
Certification of Handicapped Child's Dependency Status (PDF, 1 page, 13kb)
This form officially certifies the dependency status of a handicapped child. To be signed by the child's physician.