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Forms

MEDICAL, DENTAL, &/ or VISION

MEDICAL, DENTAL, &/ or VISION

Enrollment/Change Forms for All Medical, Dental and Vision Plans:

Disabled Adult Dependents

 
For UHC members: Please have the treating physician complete the below form and return it  directly to UHC per the instructions on the application.  UHC will notify the member of approval or denial.
 
For Kaiser members: Contact Kaiser directly at 800-464-4000, and they will send the member the form and submittal instructions.  Kaiser will notify the member of approval or denial. 
 
For Cigna Select HMO and Delta Dental members: Obtain a copy of a letter from the treating physician determining the dependent's disability and submit this with a letter requesting enrollment or continuation of coverage for the dependent to the Insurance Department.  The Insurance Department will submit the letter to our Health Benefit Trust (VEBA) for approval and notify the member of approval or denial.  
 

REIMBURSEMENT FORMS

Please return the Original Enrollment Forms to the Insurance Department along with Copies of any Supporting/Acceptable Documentation for processing. We cannot accept scanned or faxed copies of Enrollment Forms.
 
 

KAISER

 

EXPRESS SCRIPTS

If you have medical coverage with United Health Care, your prescription coverage is through Express Scripts.  Click the link below for the mail order prescription form.
 

GENERAL FORMS