| Form Name |
Available
Formats
(Icon Legend) |
Form Descriptions |
| Blue
Cross Health Care Claim Form |
|
To submit health care claims to Blue Cross/Blue Shield. |
|
Financially
Interdependent Partners Explanation |
|
To explain and determine FIP eligibility. |
|
Financially
Interdependent Partners Statement |
|
To declare FIP eligibility. |
|
FML Leave
w/o Pay (FMLWOP), Sick Leave (LWOP) Form |
|
To arrange benefit payments while on LWOP. |
| FML
Request Form |
|
To request leave for a serious health condition
(to be completed by employee). |
|
FSA Claim
For Medical And Dependent Care Form |
|
To submit a claim for your flexible spending
account. |
| FSA
Direct Deposit For Medical And Dependent Care Form |
|
To establish direct deposits of flexible
spending account payments. |
| PharmaCare
Physician Prior Authorization Request Form (for prescriptions) |
|
To be completed by patient's physician -
to request authorization for prescription exceptions (i.e., medication
usage past certain time period, specific medication brand, etc.). |
|
PharmaCare
Prescription Drug Forms
(Effective 7/1/06) |
PharmaCare
Site |
Site contains reimbursement form for prescription
drug claims; site also has other prescription related forms. |
| Student
Enrollment Verification/Dependent Health Care Eligibility |
|
To verify student enrollment and/or to notify
employees of dependent (child) health care coverage eligibility. |
| UA
Choice Health Plan Enrollment Form (All Employees) |
|
To enroll employee and dependents in UA health care plan. |
| UA
Choice Opt Out Form |
|
To elect to opt out of UA health care coverage
and show proof of other insurance. |
| UA
Choice Supplemental Benefit Election Form |
|
To add or delete employee-selected benefits
and/or deductions - i.e., FSA, AD&D, and other employee selected
deductions such as accounts payable, parking, United Way, etc. |
| VSP
Out-of-Network Reimbursement Form |
|
Effective 7/1/04: To submit a claim to VSP
(vision vendor) for out-of-network provider reimbursements. |
