Benefits Forms

These links provide access to the forms you may need to submit claims, update or add dependents, and more.

Medical

Aetna Medical Claim Form BlueCross BlueShield Claim Form CIGNA Medical Claim Form-Chattanooga CIGNA Medical Claim Form-Scranton United Healthcare Medical Claim Teladoc/Aetna HRA Claim Reimbursement Form

Prescription

Aetna Consumer Choice PPO Rx Drug Claim Form CVS Caremark Mail Order Form CVS Caremark Reimbursement Claim Form

Dental

CIGNA Dental Claim Form

Vision

VSP Out-Of-Network Reimbursement Form

Flexible Spending Accounts (FSAs)

WageWorks Pay Me Back Form - Dependent Care WageWorks Pay Me Back Form - Health Care

Life Insurance

Evidence of Insurability Form

Dependent and Family Status Changes

Benefits Consent Form Beneficiary Designation Form Disabled Dependent Certification Domestic Partnership Affidavit Domestic Partnership Tax Certification Domestic Partnership Termination Status Change Form - Hourly Status Change Form - Salaried Status Change Form - Union Expatriate Affidavit

Other

HIPAA Authorization Form