Select a form from the list below.
Employee / Member
CEBT HIPAA Documents
Caremark (prescription drug coverage provider)
Prescription Drug Mail Order Form
Prescription Drug Standard Claim Form
UMR
UMR Other Insurance Form
UMR Dental Claim Form
*Only use this form for claims incurred prior to 1/1/2019
UMR Possible Third Party Liability Form
Kaiser
Kaiser Student Certification Form
Delta Dental
Dental Claim Form
*Only use this form for claims incurred on or after 1/1/2019
VSP
Vision Care Out of Network Reimbursement Form
*You could also submit your claim online at vsp.com
Standard Insurance Company
Voluntary Life Medical History Statement
Employer / Payroll / Human Resource
CEBT
Evidence of Group Health Coverage
General
Affidavit of Common Law Marriage
CEBT General Notice of COBRA Continuation Coverage Rights
Medicaid and the Children’s Health Insurance Program (CHIP)
Section 1557 - Nondiscrimination Notice