Forms & Documents
This form is to be completed when enrolling new employees or changing existing coverage information.
This form is to be completed when enrolling a new over-age-dependant or changing existing coverage information.
Form is to used for Third Party Administration (TPA) when enrolling new employees or changing existing coverage information.
Document lists minimum hardware and software requirements for users of ClaimSecure web services.
This form is to be completed when submitting a dental claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
This form is to be completed when submitting a drug claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
This form is to be completed when submitting a major medical claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
This form is to be completed when submitting an HSSA claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
This form is to be completed when submitting a Wellness claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
List of Formulary Select drugs and alternatives in the same therapeutic class.
An interactive document that contains member/dependant coverage details and data format elements for electronic file submissions.
List of Specialty drugs only. These drugs may be classified as "Requires Special Authorization" by the plan sponsor – plan members may download this list and provide it to their Healthcare Providers.
Answers to frequently asked questions relating the Special Authorization process.
This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.
This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.
List of all drugs that may be classified as “Requires Special Authorization” by the plan sponsor under our Managed Plans, including specialty medication.
This 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.
This 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.
This 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.
This questionnaire is to be completed when submitting a Wheelchair estimate. Be sure to complete all required information and submit an estimate, prior to approval.
Quickly and easily find all the forms you are looking for on this page. Either browse through the list of forms below or search by using keywords using the search field below. Once you’ve found your form you can download it in PDF format using the “download” link.
Not sure which form you need? You can also search by using keywords.This form is to be completed when enrolling new employees or changing existing coverage information.
This form is to be completed when enrolling a new over-age-dependant or changing existing coverage information.
This form is to be completed when submitting a dental claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
This form is to be completed when submitting a drug claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
This form is to be completed when submitting a major medical claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
Health Service Spending Account (HSSA)
This form is to be completed when submitting a Wellness claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
List of Formulary Select drugs and alternatives in the same therapeutic class.
Answers to frequently asked questions relating the Special Authorization process.
This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.
List of all drugs that may be classified as “Requires Special Authorization” by the plan sponsor under our Managed Plans, including specialty medication.
List of Specialty drugs only. These drugs may be classified as "Requires Special Authorization" by the plan sponsor – plan members may download this list and provide it to their Healthcare Providers.
This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.
This claim form should be completed when an individual whose plan design includes mandatory generic is applying for coverage for the full cost of the brand name drug.
This form is to be completed when an individual is accessing the coverage navigation service for assistance applying to government and/or manufacturer sponsored programs for Specialty Drug coverage.
This 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.
This 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.
This 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.
This questionnaire is to be completed when submitting a Wheelchair estimate. Be sure to complete all required information and submit an estimate, prior to approval.
Quickly and easily find all the forms you are looking for on this page. Either browse through the list of forms below or search by using keywords using the search field below. Once you’ve found your form you can download it in PDF format using the “download” link.
Not sure which form you need? You can also search by using keywords.This form is to be completed when enrolling new employees or changing existing coverage information.
This form is to be completed when enrolling a new over-age-dependant or changing existing coverage information.
Form is to used for Third Party Administration (TPA) when enrolling new employees or changing existing coverage information.
Document lists minimum hardware and software requirements for users of ClaimSecure web services.
This form is to be completed when submitting a dental claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
This form is to be completed when submitting a drug claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
This form is to be completed when submitting a major medical claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
This form is to be completed when submitting an HSSA claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
This form is to be completed when submitting a Wellness claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
List of Formulary Select drugs and alternatives in the same therapeutic class.
An interactive document that contains member/dependant coverage details and data format elements for electronic file submissions.
Answers to frequently asked questions relating the Special Authorization process.
This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.
List of Specialty drugs only. These drugs may be classified as "Requires Special Authorization" by the plan sponsor – plan members may download this list and provide it to their Healthcare Providers.
This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.
List of all drugs that may be classified as “Requires Special Authorization” by the plan sponsor under our Managed Plans, including specialty medication.
This 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.
This 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.
This 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.
This questionnaire is to be completed when submitting a Wheelchair estimate. Be sure to complete all required information and submit an estimate, prior to approval.
Quickly and easily find all the forms you are looking for on this page. Either browse through the list of forms below or search by using keywords using the search field below. Once you’ve found your form you can download it in PDF format using the “download” link.
Not sure which form you need? You can also search by using keywords.Form and Agreement to be signed by pharmacy in order to connect and transmit real time drug claims to ClaimSecure.
Form for provider Direct Deposit registration
This form is to be completed when submitting a dental claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
This form is to be completed when submitting a drug claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
This form is to be completed when submitting a major medical claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
This form is to be completed when submitting an HSSA claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
This form is to be completed when submitting a Wellness claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
List of all drugs that may be classified as “Requires Special Authorization” by the plan sponsor under our Managed Plans, including specialty medication.
This 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.
This 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.
This 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.
This questionnaire is to be completed when submitting a Wheelchair estimate. Be sure to complete all required information and submit an estimate, prior to approval.
Quickly and easily find all the forms you are looking for on this page. Either browse through the list of forms below or search by using keywords using the search field below. Once you’ve found your form you can download it in PDF format using the “download” link.
Not sure which form you need? You can also search by using keywords.Quickly and easily find all the forms you are looking for on this page. Either browse through the list of forms below or search by using keywords using the search field below. Once you’ve found your form you can download it in PDF format using the “download” link.
Not sure which form you need? You can also search by using keywords.
This form is to be completed when enrolling new employees or changing existing coverage information.
This form is to be completed when enrolling a new over-age-dependant or changing existing coverage information.
Form is to used for Third Party Administration (TPA) when enrolling new employees or changing existing coverage information.
Document lists minimum hardware and software requirements for users of ClaimSecure web services.
This form is to be completed when submitting a dental claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
This form is to be completed when submitting a drug claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
This form is to be completed when submitting a major medical claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
This form is to be completed when submitting an HSSA claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
This form is to be completed when submitting a Wellness claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
List of Formulary Select drugs and alternatives in the same therapeutic class.
An interactive document that contains member/dependant coverage details and data format elements for electronic file submissions.
Answers to frequently asked questions relating the Special Authorization process.
This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.
List of Specialty drugs only. These drugs may be classified as "Requires Special Authorization" by the plan sponsor – plan members may download this list and provide it to their Healthcare Providers.
This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.
List of all drugs that may be classified as “Requires Special Authorization” by the plan sponsor under our Managed Plans, including specialty medication.
This 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.
This 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.
This 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.
This questionnaire is to be completed when submitting a Wheelchair estimate. Be sure to complete all required information and submit an estimate, prior to approval.
This form is to be completed when enrolling new employees or changing existing coverage information.
This form is to be completed when enrolling a new over-age-dependant or changing existing coverage information.
This form is to be completed when submitting a dental claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
This form is to be completed when submitting a drug claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
This form is to be completed when submitting a major medical claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
Health Service Spending Account (HSSA)
This form is to be completed when submitting a Wellness claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
List of Formulary Select drugs and alternatives in the same therapeutic class.
Answers to frequently asked questions relating the Special Authorization process.
This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.
List of all drugs that may be classified as “Requires Special Authorization” by the plan sponsor under our Managed Plans, including specialty medication.
List of Specialty drugs only. These drugs may be classified as "Requires Special Authorization" by the plan sponsor – plan members may download this list and provide it to their Healthcare Providers.
This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.
This claim form should be completed when an individual whose plan design includes mandatory generic is applying for coverage for the full cost of the brand name drug.
This form is to be completed when an individual is accessing the coverage navigation service for assistance applying to government and/or manufacturer sponsored programs for Specialty Drug coverage.
This 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.
This 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.
This 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.
This questionnaire is to be completed when submitting a Wheelchair estimate. Be sure to complete all required information and submit an estimate, prior to approval.
This form is to be completed when enrolling new employees or changing existing coverage information.
This form is to be completed when enrolling a new over-age-dependant or changing existing coverage information.
Form is to used for Third Party Administration (TPA) when enrolling new employees or changing existing coverage information.
Document lists minimum hardware and software requirements for users of ClaimSecure web services.
This form is to be completed when submitting a dental claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
This form is to be completed when submitting a drug claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
This form is to be completed when submitting a major medical claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
This form is to be completed when submitting an HSSA claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
This form is to be completed when submitting a Wellness claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
List of Formulary Select drugs and alternatives in the same therapeutic class.
An interactive document that contains member/dependant coverage details and data format elements for electronic file submissions.
List of Specialty drugs only. These drugs may be classified as "Requires Special Authorization" by the plan sponsor – plan members may download this list and provide it to their Healthcare Providers.
Answers to frequently asked questions relating the Special Authorization process.
This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.
This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.
List of all drugs that may be classified as “Requires Special Authorization” by the plan sponsor under our Managed Plans, including specialty medication.
This 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.
This 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.
This 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.
This questionnaire is to be completed when submitting a Wheelchair estimate. Be sure to complete all required information and submit an estimate, prior to approval.