Forms
Forms & Documents
Claim Forms
General Appeal Form
Health Club Reimbursement
Health Education Reimbursement – CIGNA
Massage Therapy Reimbursement
Short Term Disability Application
EyeMed Out-Of-Network Claim Form
Hearing Reimbursement Form
Dental
Dental Benefit Frequency Breakdown
Allegiant Care Dental Fee Schedule 2023
Allegiant Care Dental Fee Schedule 2024
Enrollment Forms
Address Change Form
General Enrollment Form
COBRA Continuation Form
Coordination of Benefits
Dependent Termination Form
Life Insurance Beneficiary Designation
Health Insurance Portability and Accountability Act (HIPAA)
Authorization to Discuss Protected Health Information
Prescription
Prescription Benefit Limitations
Retiree Enrollment
2022 Blue MedicareRx Drug Formulary
2023 Blue MedicareRx Drug Formulary
Authorization to Deduct Premium from Pension
Blue MedicareRx – Shingles Vaccince
Blue MedicareRx – Mail Service Order Form
Pre-Medicare Retiree Application
