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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. 02/13/2019)
Change of Address Form (Rev. 06/29/2018)
Disability Benefits Beneficiary Designation (Rev. 08/08/2018)
Disability Reimbursement Agreement (Rev. 05/06/2020)
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
