As COVID-19 continues to spread both nationally and locally, the health of our associates is our top priority. Effective Monday, March 23, 2020, and until further notice, our physical office and call center are closed, and the majority of our associates are working remotely. Learn more about how we’re continuing to serve our customers during this time.
Authorization Form Granting Access to PHI - Insured Clients (PDF, 3 pages, 52kb)
Authorization Form Granting Access to PHI - Self Funded Clients (PDF, 3 pages, 51kb)
Eligibility Enrollment Change Form (PDF, 2 pages, 22kb)
Use this form to submit new adds, changes, and terminations.
COBRA Application (PDF, 1 page, 63kb)
Certification of Handicapped Child's Dependency Status (PDF, 1 page, 13kb)
This form officially certifies the dependency status of a handicapped child. To be signed by the child's physician.