Employee Assistance Program Supervisor Referral Form
Student Accident/Incident Report
Legal Shield Application
Health Plan Selection Form
Use this form to request a change in the amount you deduct from your check to be deposited into your HSA if your account is at Iberia Bank. You can change this deduction any time during the year. If your account is at the Credit Union, you must go to their location to make a change.
PRESCRIPTION DRUG CLAIM FORMS
Express Scripts Prescription Drug Mail Order Form Order a 90-day supply of your maintenance medication with this form. This form should be mailed to Express Scripts, Mail Pharmacy Service, PO Box 52123, Phoenix, AZ 85072-2123.
BLUE CROSS BLUE SHIELD FORMS
Health Plan Enrollment Form This is the form you must complete to enroll in the health plan if you are not currently enrolled.Dependent Certification Form This is a Blue Cross Blue Shield form used to verify that your dependent child over the age of 21 is a full-time student.
Blue Cross Blue Shield coverage cancellation form .
Blue Cross Blue Shield Claim Form This is the claim form used to file your medical claims.
Authorized Delegate Form This is the form employees on the health plan may complete and submit to Blue Cross to give Blue Cross permission to share protected health information with others, such as a family member or the Insurance Department staff. You must provide this written permission to Blue Cross if you want the Insurance Department staff or a family member to get information on your claims. Without this written permission, HIPAA prevents Blue Cross from speaking to anyone about your health information.
Other Coverage Questionnaire This is a form BCBS occasionally requests employees complete when they are checking for other coverage available to a plan member. That information is needed for coordination of benefits.
LIFE INSURANCE FORMS
Beneficiary Designation Form Use this form for your initial selection of your life insurance beneficiaries or to change your beneficiary designations.
Life insurance enrollment form Use this form to enroll in life insurance.
For information regarding voluntary benefits such as disability coverage, vision, and dental visit First Financial Group of America .