Forms and Documents Active Employee

Forms and Documents

Health, Flexible Benefits, and Life Insurance	To view, click on one of the documents listed below. Claim Form Health, Med Spending, Dependent Care Dental Vision Short Term Disability Major Injury Protection Hospital Indemnity FY 2012 Claim Form FY 2013 Decision Guide (updated 7/1/2012) DAKOTACARE Direct Deposit Authorization Form DAKOTACARE Flex Orthodontia Claim Form Evidence of Insurability Form Family Status Change Form Health Savings Account Form Incapacitated Dependent Child Form Life/Beneficiary Electronic Enrollment Form Life Enrollment Form Short Term Disability Claim Form Student Verification Form Tobacco Use Election Form Waiver of Life Premium Form
Pharmacy	Express Scripts (ESI) Prescription Drug Claim Form ESI Pharmacy List FY 2013 Formulary FY 2013 Maintenance Drug List
Other	FY 2013 Contracted Facilities for CT/MRI/PET Confirmation Statement/Current Coverage FY 2012 and FY 2013 Health Plan Comparison Chart FY 2013 Factsheet FY 2014 Factsheet Health Assessment Health Screening FY 2013 Pre-authorization Listing RFP 2069 RFP 2055
Frequently Asked Questions (FAQS)	FY 2013 Latitude Health Plan ($500 Deductible) $1,000 Deductible Plan $1,800 Deductible Plan HSA Compatible Health Assessment Prescription Drug FAQ for Latitude Health Plan ($500 Deductible) and $1,000 Deductible Plan
Privacy	Authorization for Use and Disclosure of Health Information Form Notice of Privacy Practices