Access Forms

We are committed to keeping you up-to-date on all aspects of your benefit plan. Download important forms here.

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Forms for Employers


PDF icon Employer Portal Access Form

COBRA Enrollment

PDF icon COBRA Qualifying Event Termination

Forms for Members


PDF icon Online Access / PHI Disclosure Form

PDF icon Member Authorization to Obtain PHI

PDF icon Member Authorization to Release PHI



PDF icon Dependent Enrollment Form

Member Appeal

PDF icon Member Appeal Form

Member Reimbursements

PDF icon Standard Medical Claim Form

PDF icon Member Reimbursement Form  green starsubmit your request in My Plan


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