Member Forms

• Authorization on to Release Information
• Dental Claim Form
• Medical Claim Form
• Balance Billing Protection Notice - Self Funded

Fully Insured Member Forms

• You are a member of a Fully Insured plan if the Group Number on your ID card begins with a number.
• Change Request Form
• Employee Dental Enrollment Form
• Employee Vision Enrollment Form
• Balance Billing Protection Notice - Fully Insured