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

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.

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

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.

Other Coverage & Overage Student Form – if information about other health insurance coverage on you or a covered dependent changes, complete this form. If you are covering a child who is a full-time student age 24 or older, you must complete sections I and V of this form at the beginning of each term except the summer term. The Plan assumes a child who was a full-time student at the beginning of the summer who has not graduated and who does not enroll for the summer term will be returning to school as a full-time student for the fall term. In such case the student remains covered during the summer term even though not enrolled.

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.