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S M T W T F S

FORMS


All forms are available in PDF format.  To download the free PDF reader software click here.

 

Pre-Notification (Specialist Referral) or Precertification for inpatient care and certain outpatient procedures - have your PCP complete this form for referrals to Specialists or your treating provider complete this form for inpatient care or certain outpatient procedures in order to receive the greatest available benefits under the Plan. See your Plan ID card  for details.

 

Enrollment form - newly eligible employees complete this form in order to become covered under the Plan, to list dependents to be covered and to provide information about any other coverage the employee or a covered dependent may have. 

 

Change Form – covered employees who have a change in status event and wish to make an enrollment change. NOTE: It is YOUR RESPONSIBILITY to notify the Plan through your school of a change in status other than a change in your employment status within 31 days of the event.  Failure to give notice will result in your not being able to make a change for that event and may result in your continuing to pay for coverage which no longer applies, such as for a dependent child who lost eligibility or a spouse who now has coverage elsewhere.

 

Additional Dependents Form - if the enrollment or change form does not provide enough space to list all dependents, use this form to provide dependent information and attach it to the enrollment or change form. 

 

Other Coverage Form – if information about other health insurance coverage on you or a covered dependent changes, complete this form. 

 

Accident Claim Form – if expenses are the result of an accidental injury, REGARDLESS OF CAUSE, complete all applicable sections of this form in order to help determine who is responsible for paying the expenses. If another party may be financially responsible, complete and sign the Subrogation section of the form. Our claims administrator will NOT pay an accident related claim until they receive this information.

 

Termination & COBRA Form – complete this document when an employee or dependent terminates coverage for any reason. Always complete Section I and either Section III or IV. If a dependent is involved complete Section II. Human Resources must complete the employer section at the bottom of the form.

 

Authorization for Release of Health Information - In the event a covered participant or dependent wishes to authorize the claims administrator or the Consortium office to be able to discuss a claim situation with another individual such as a spouse or a Human Resources Representative, this form must be completed and provided to the claims administrator or the Consortium office BEFORE any such discussion may take place.  For more information on this subject, please read our Privacy Practices.