Skip to main content
Menu
Social Icons
Facebook
Twitter
Youtube
Gov Delivery
Office of Management and Enterprise Services
About
Administration
Boards & Commissions
Contact
Divisions
Laws & Rules
Newsroom
Media Room
Services
Budget
Capital Planning
Capitol Event Reservation
Central Accounting & Reporting
Central Printing & Interagency Mail
Construction & Properties
Employee Benefits
Employees Group Insurance Division
Facilities Management
Fleet Management
Gaming Compliance Unit
HealthChoice
Human Capital Management
Information Services
Purchasing
Real Estate & Leasing Services
Risk Management
Surplus
State
Federal
Statewide Learning Services
Workforce Planning
Careers
Search form
Search
Search
You are here
Home
Services
HealthChoice
Member
Forms & Applications
Forms & Applications
Accidental Dismemberment or Loss of Sight Claim Form (Rev. 03/25/2019)
American Fidelity Health Savings Account Application
Application for Life Premium Waiver- For use by Entities with the EGID Disability Plan
Application for Medicare Advantage Prescription Drug (MAPD) Plan (Rev. 09/23/2019)
Application for Medicare Supplement With Prescription Drug Plan (Rev. 10/14/2019)
Application for Retiree/Vested/Non-Vest/Defer Insurance (Rev. 10/24/2019)
Authorization to Disclose HealthChoice Information (Rev. 10/11/2018)
Beneficiary Designation Form (Rev. 05/06/2019)
Certification of Previous Coverage (Rev. 2/13/2019)
Change of Address Form (Rev. 06/29/2018)
Disability Benefits Beneficiary Designation (Rev. 8/8/2018)
Durable Power of Attorney
Electronic Fund Transfer Authorization (Rev. 3/21/2019)
Life Insurance Claim Form Packet
Medicare Complaint Form - Health or Prescription Coverage
Medicare Part D Prescription Claim Form
Member Audit Form (Rev. 12/20/2017)
Prescription Reimbursement Claim Form
Revocation of Authorization to Disclose HealthChoice Information (Rev. 1/26/2016)
TRICARE Supplement
