Employee / Member

CEBT HIPAA Documents

CEBT HIPAA Notice of Privacy Policy

HIPAA Release Form

Caremark (prescription drug coverage provider)

Prescription Drug Mail Order Form

Prescription Drug Standard Claim Form

UMR

UMR Other Insurance

UMR Other Insurance

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

Appeal Process

Delta Dental

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

Standard Insurance Company

Life Conversion Request Form

Life Portability Application

Voluntary Life Medical History Statement

CEBT Life Claim Packet

VSP

Vision Care Out of Network Reimbursement Form

You could also submit your claim online at vsp.com

Employer / Payroll / Human Resource

CEBT

CEBT Enrollment / Change Card

Kaiser 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

Group Supply Request

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

Hospital Reimbursement Plan (HRP)

Section 1557 - Nondiscrimination Notice

Kaiser Student Certification Form

The Standard

Life and AD & D Claim Form

Life Conversion Request Form

Life Portability Application

Life Waiver of Premium

Travel Assistance Program

Travel Assistance Employee Brochure

Employee Flyer