Anthem/CarelonRx Prescription Coverage - For High Deductible Health Plans (HDHP)
Anthem CarelonRx Mail Service Order Form [1.01 Mb]
Anthem CarelonRx Prescription Reimbursement Claim Form [183 Kb]
Benefit Advantage FSA/HRA Services
Benefit Advantage List of Eligible Expenses [58 Kb]
Change in Status Form [281 Kb]
Direct Deposit Authorization Form [53 Kb]
Election Worksheet [74 Kb]
FSA Claim Form [244 Kb]
Physician Statement [105 Kb]
Void & Reissue Form [372 Kb]
Claims
Anthem Subscriber Claim Form [46 Kb]
CVS Caremark Prescription Reimbursement Claim Form [171 Kb]
Northeast Delta Dental Claim Form [747 Kb]
STD-Disability Income Benefits, Claim and Disability Status Form [293 Kb]
CVS Caremark Prescription Coverage
CVS Caremark Mail Service Order Form [318 Kb]
CVS Caremark Prescription Reimbursement Claim Form [171 Kb]
Flyers
Benefit Advantage FSAs - Information for Employees [1.48 Mb]
Life, Long-Term Disability and Short-Term Disability Enrollment
Life LTD STD Fillable Application Form [134 Kb]
Medical and Dental Enrollment
Annuity Deduction Authorization for Medical and Dental Benefits Fillable Form [433 Kb]
Anthem Site of Service ASC Listing [59 Kb]
Anthem Site of Service Lab Listing [103 Kb]
Certificate of Tax Dependent Status for a Domestic Partner [363 Kb]
Certification for a Mentally or Physically Disabled Dependent Child Over Maximum Age [1.35 Mb]
COBRA Coverage ACH Authorization Form [108 Kb]
Dental Application and Change Fillable Form [213 Kb]
Domestic Partner Statement of Termination [143 Kb]
Domestic Partners Affidavit [138 Kb]
Information Update/Correction Form [235 Kb]
Medical and/or Dental Application and Change Fillable Form [265 Kb]
Notice of Divorce or Legal Separation [129 Kb]
Notice of Membership Changes Fillable Form [345 Kb]
Retiree Medical and/or Dental Application and Change Fillable Form [209 Kb]
Medicare Supplemental Plan (Medicomp Three)
Medicomp Three brochure [121 Kb]
Retiree ACH Authorization Form Fillable PDF [69 Kb]
Privacy and Security (HIPAA)
HIPAA Authorization to Release Information [172 Kb]
Instructions for Completing HIPAA Authorization to Release Information Form [107 Kb]
Notice of Privacy Practices [159 Kb]
Notice of Privacy Practices - ComPsych Corporation [33 Kb]
Request for Accounting of Disclosures [33 Kb]
Request for Confidential Communications [27 Kb]
Request for Restriction on Uses and Disclosures [33 Kb]
Request to Amend a Record [33 Kb]
Request to Inspect Health Information [34 Kb]
Revocation of Authorization to Release Information [29 Kb]
Secure Member Portal Authorized User Access Form [120 Kb]
Termination of Restriction on Use and Disclosures [28 Kb]
Provider Directories
Anthem Site of Service ASC Listing [59 Kb]
Anthem Site of Service Lab Listing [103 Kb]
Requirements and Helpful Hints
Helpful Hints When Completing The Annuity Deduction Authorization for Medical and Dental Benefits Form [407 Kb]
Helpful Hints When Completing the Medical and/or Dental Application and Change Form [215 Kb]
Helpful Hints When Completing the Retiree Medical and/or Dental Application and Change Form [224 Kb]
Wellness Coordinator Forms and Resources
2026 Wellness Coordinator Application [128 Kb]