Employer Forms

Click on the Form link to view.

Subject ( State: AZ )

Application-Medical (for addition of employees to large groups with medical coverage)

Application-Non-Medical (for additions to all large groups and small groups without medical coverage)

Authorization Privacy Form

Authorization to Disclose Protected Health Information

AZ Claim Form for Disability Benefits

AZ Dependent Addition Form (for addition of dependents)

Caremark Prescription Reimbursement Claim Form

Change Request Form (Address Change, Name Change, Beneficiary Change)

Claim Form for Disability Benefits (use for initial notification of disability claim)

Claim Form for Disability Benefits-Supplemental (use to continue benefits on existing claim)

Claim Form for Life Insurance

Employee and Family Medical Questionnaire (for addition of employees to small groups with medical coverage)

Group HSA Fund Checklist

Group Premium Statement Guide

HSA Employee Enrollment Form

Request for Treatment as an Assistance Eligible Individual

Summary of the COBRA Premium Reduction Provisions under ARRA

Termination of Coverage Request Form