July 31, 2010  Forms - Member member | provider | advisor | plan sponsor Claim Forms Special Authorization Forms Administrative Forms Specialized Forms/Questionnaires To print and/or view a form, please click on a link below . To save to your hard drive for viewing and/or printing at a later time, right-click on the link, click "Save Target As", and select where you want to save the file on your hard drive. Indicates a secure file, downloadable by authorized users only. Passwords will be changed regularly for security reasons. If you are a member and wish to view the file, or believe you may be using an old password, contact ClaimSecure for access.   Note: Some forms require Adobe Acrobat to view. Click below to download Adobe Acrobat Reader:  Claim Forms Form Name Size Format Description Dental   237KB PDF Form is to be completed when submitting a dental claim for reimbursement. Be sure to include an original receipt along with completed claim form. Drug   161KB PDF Form is to be completed when submitting a drug claim for reimbursement. Be sure to include an original receipt along with completed claim form. Health Service Spending Account (HSSA)   132KB PDF Form is to be completed when submitting a HSSA claim for reimbursement. Be sure to include an original receipt along with completed claim form. Hospital   77KB PDF Form is to be completed when submitting a hospital claim for reimbursement. Be sure to include an original receipt along with completed claim form. Extended Health Care   30KB PDF Form is to be completed when submitting a major medical claim for reimbursement. Be sure to include an original receipt along with completed claim form. Vision   34KB PDF Form is to be completed when submitting a vision claim for reimbursement. Be sure to include an original receipt along with completed claim form. back to top  Special Authorization Forms Form Name Size Format Description Anti-Obesity   58KB PDF Claim form to be completed when individual is applying for a drug that requires clinical review prior to approval. Drug and Approval Guidelines   196KB PDF List of drugs that may be classified as “Requires Special Authorization” by the plan sponsor – plan members may download and present to their Healthcare Providers Specialty Drugs and Approval Guidelines   132KB PDF List of Specialty drugs that may be classified as "Requires Special Authorization" by the plan sponsor – plan members may download and present to their Healthcare Providers Erectile Dysfunction   62KB PDF Claim form to be completed when individual is applying for a drug that requires clinical review prior to approval. Standard   79KB PDF Claim form to be completed when individual is applying for a drug that requires clinical review prior to approval. back to top  Administrative Forms Form Name Size Format Description Enrollment Form   160KB PDF Form is to be completed when enrolling new employees or changing existing coverage information. Explanation of Benefits - Sample   341KB PDF Statement describing submitted and paid claim details by line of benefit, explanation of adjustments and/or rejections and address details. OAD Eligibility Form   167KB PDF Form is to be completed when enrolling a new over-age-dependent or changing existing coverage information. TPA Enrollment Form   230KB PDF Form is to used for Third Party Administration (TPA) when enrolling new employees or changing existing coverage information. back to top  Specialized Forms/Questionnaires Form Name Size Format Description Nursing Care Assessment Form   176KB PDF Questionnaire is to be completed when submitting a Nursing Care estimate. Be sure to complete all required information and submit an estimate, prior to approval Wheelchair Rental Questionnaire   178KB PDF Questionnaire is to be completed when submitting a Wheelchair estimate. Be sure to complete all required information and submit an estimate, prior to approval Hospital Bed Assessment Form   150KB PDF Questionnaire is to be completed when submitting a Hospital Bed estimate. Be sure to complete all required information and submit an estimate, prior to approval Custom Knee Brace Questionnaire   126KB PDF Questionnaire is to be completed when submitting a Custom Knee Brace estimate. Be sure to complete all required information and submit an estimate, prior to approval back to top