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Forms

If you need a form not listed here, please contact Human Resources to request it.

Office Supplies

Dental

Dental Claim Form

Flexible Spending Accounts

FSA Claim Form

FSA Claim Instructions

FSA Direct Deposit Authorization

HIPAA Authorization

Health

BCBS Claim Form

BCBS HIPAA Authorization

BCBS Rx Claim Form

BlueCard Worldwide International Claim Form

Prime Speciality Order Form

PrimeMail Order Form

HRA – Health Reimbursement Arrangement

Lucent Health HRA Direct Deposit Form

Lucent Health HRA Reimbursement Form

HSA – Health Savings Account

HSA Account Closure Form

HSA Beneficiary Designation Form

HSA Enrollment Verification Form

Retirement

Empower Beneficiary Form

Tax Reports

Tax Form 1095–C

Well-being Program

Biometric Screening Certification Form

Wellness Program Appeal

Well-being Reimbursement Instructions & Form