Employee / Member

CEBT HIPAA Documents

CEBT HIPAA Release Form

Caremark (prescription drug coverage provider)

Prescription Drug Mail Order Form

Prescription Drug Standard Claim Form

UMR

UMR Other Insurance Form

UMR Other Insurance Form

UMR Dental Claim Form
*Only use this form for claims incurred prior to 1/1/2019

UMR Medical/Vision Claim Form

UMR Possible Third Party Liability Form

Kaiser

Kaiser Student Certification Form

Kaiser Member Claim Reimbursement Form

Delta Dental

Dental Claim Form
*Only use this form for claims incurred on or after 1/1/2019

VSP

Vision Care Out of Network Reimbursement Form
*You could also submit your claim online at vsp.com

Standard Insurance Company

Life Conversion Request Form

Life Portability Application

Voluntary Life Medical History Statement

CEBT Life Claim Packet

Life Waiver of Premium due to Disability Form

Life and AD&D Claim Form

SDA LTD Claim Packet

SDA STD Claim Packet

Employer / Payroll / Human Resource

CEBT

CEBT Enrollment / Change Card

Evidence of Group Health Coverage

CEBT Notice of Termination

General

Affidavit of Common Law Marriage

CEBT General Notice of COBRA Continuation Coverage Rights

Group Supply Request Form

Group Supply Request Form

Medicaid and the Children’s Health Insurance Program (CHIP)

Section 1557 - Nondiscrimination Notice

Travel Assistance Program

Travel Assistance Employee Brochure

Employee Flyer