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Home
Services
HealthChoice
Member
Forms & Applications
Forms & Applications
Accidental Dismemberment or Loss of Sight Claim Form (Rev. 4/11/2013)
American Fidelity Health Savings Account Application
Application for Life Premium Waiver- For use by Entities with the EGID Disability Plan
For 2020 Enrollments –
Application for Medicare Advantage Prescription Drug (MAPD) Plan (Rev. 09/23/2019)
For 2019 Enrollments –
Application for Medicare Advantage Prescription Drug (MAPD) Plan (Rev. 8/21/2018)
Application for Medicare Supplement With Prescription Drug Plan (Rev. 10/14/2019)
Application for Retiree/Vested/Non-Vest/Defer Insurance (Rev. 10/8/2018)
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
