Medical Forms


Medical Plan Enrollment Form With Dental
Medical Plan Enrollment Form No Dental
Household Member Enrollment Form  
UMR Medical Reimbursement Form
Priority Health Medical Reimbursement Form


Caremark Mail Order Prescription Form
Caremark Prescription Reimbursement Form

Delta Dental Claim Form

Health Savings Account
HSA Contribution Form
HSA Expense List

Flexible Spending
Health Care Account Reimbursement Request form (UMR for 2013 claims)
Dependent Care Account Reimbursement Request form (UMR for 2013 claims)
FSA Expense List
FSA Worksheet
FSA Mileage Form
FSA Direct Deposit Authorization Form

Flexible Spending Account Reimbursement Form (Infinisource for 2014 claims)
Consumer Portal Quick Start Guide (Infinisource for 2014 )
FSA Worksheet (Infinisource)

FSA Enrollment Form

EyeMed Out-of-Network Claim Form 

Priority Health Vision Out of Network Claim Form


Can't find the form you want?  Return to the Benefits Forms Main Page.  If you are unable to find the form, feel free to contact Benefits at x12220 for assistance.

If you have recently visited our site to obtain a form using Internet Explorer, please delete your temporary internet files.  On your Internet Explorer menu, click "tools" and then "internet options".  Under the General tab, temporary internet files, then click "delete files".  This will allow you to obtain the most recent copy of the form


Page last modified February 11, 2014