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Forms

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Health Insurance 34535-G-0308

Authorization for Disclosure of Personal Information (General)

Health Insurance 34534-0503

Authorization for Disclosure of Specific Personal Information (One occurrence only)

Health Insurance 1044-G-0508

Authorization to Obtain & Disclose Information

Health Insurance 1044KY-G-0508

Authorization to Obtain & Disclose Information (KY)

Health Insurance 1044LA-G-0508

Authorization to Obtain & Disclose Information (LA)

Health Insurance 1044NC-G-0508

Authorization To Obtain & Disclose Information (NC)

Health Insurance 1044NM-G-0508

Authorization to Obtain & Disclose Information (NM)

Health Insurance 1044OK-G-0508

Authorization to Obtain & Disclose Information (OK)

Health Insurance 848-G-0908

Change of Beneficiary Agreement

Health Insurance cabca2-G-1107

Claim Form for AR, AZ, CA, LA, TX

Health Insurance cabCO2-G-1107

Claim Form for CO

Health Insurance cabFL2-G-1107

Claim Form for FL

Health Insurance cabIN2-G-1107

Claim Form for IN and NH

Health Insurance cabKY2-G-1107

Claim Form for KY

Health Insurance cabnj2-G-1107

Claim Form for NJ

Health Insurance cabNM2-G-1107

Claim Form for NM

Health Insurance cabOK2-G-1107

Claim Form for OK

Health Insurance cabPA2-G-1107

Claim Form for PA

Health Insurance cabst2-G-1107

Claim Form Standard (for all other states)

Health Insurance 37444-G-1008

Disclosure of Dental Coverage (IL)

Health Insurance 790-1206F

EFT Authorization

Health Insurance 002C-799

Health Insurance Certification for AK, DE, MD, OK, TN, VA, & WI

Health Insurance 953B-799

Health Insurance Certification for AL, AZ, DC, FL, IL, IN, IA, KS, KY, MI, MO, MS, NM, PA, SC, TX

Health Insurance 063B-799

Health Insurance Certification for CO

Health Insurance 120D-0405

Health Insurance Certification for CT & NM

Health Insurance 074C-799

Health Insurance Certification for GA, NE, OH, WV

Health Insurance 520D-0408

Health Insurance Certification for SD

Health Insurance HMI-0106

Heart Murmur Inquiry

Health Insurance 38226-G-0609

HSA Handbook - Optum

Health Insurance 155X-1108

OptumHealthBank HSA Application

Health Insurance 31237-G-0408

Qualified Medical Expenses

Health Insurance 343D-G-0109

Reinstatement Application for AK, NE, SD, & WY

Health Insurance 811C-G-1008

Reinstatement Application for AL

Health Insurance 812C-G-1208

Reinstatement Application for AR

Health Insurance 090D-G-1208

Reinstatement Application for AZ

Health Insurance 865B-0403

Reinstatement Application for CA

Health Insurance 601D-G-1108

Reinstatement Application for CO - Association Group (FACT Fee)

Health Insurance 600D-G-1108

Reinstatement Application for CO - True Individual

Health Insurance 119D-G-1208

Reinstatement Application for CT - Association Group (FACT Fee)

Health Insurance 495D-G-0209

Reinstatement Application for CT - True Individual

Health Insurance 814C-G-0908

Reinstatement Application for DC

Health Insurance 673D-G-0609

Reinstatement Application for DE

Health Insurance 480D-G-1008

Reinstatement Application for FL - Association Group (FACT Fee)

Health Insurance 836C-G-0908

Reinstatement Application for FL - True Individual

Health Insurance 475C-G-1208

Reinstatement Application for GA - Association Group (FACT Fee)

Health Insurance 270D-G-0908

Reinstatement Application for GA - True Individual

Health Insurance 870B-G-0808

Reinstatement Application for HI, MT, & NH

Health Insurance 224D-0308

Reinstatement Application for IA

Health Insurance 815C-G-1208

Reinstatement Application for ID

Health Insurance 479D-G-0708

Reinstatement Application for IL

Health Insurance 099D-G-0309

Reinstatement Application for IN

Health Insurance 264D-0407

Reinstatement Application for KS

Health Insurance 247D-1107

Reinstatement Application for KY - Association Group (FACT Fee)

Health Insurance 490D-G-0708

Reinstatement Application for KY - True Individual

Health Insurance 671D-G-0609

Reinstatement Application for LA

Health Insurance 863B-0408

Reinstatement Application for MA, OR, RI, and UT

Health Insurance 714D-G-0609

Reinstatement Application for MD

Health Insurance 721C-0403

Reinstatement Application for ME

Health Insurance 096D-G-0908

Reinstatement Application for MI

Health Insurance 726C-0403

Reinstatement Application for MN

Health Insurance 107D-G-0908

Reinstatement Application for MO

Health Insurance 798C-G-0309

Reinstatement Application for MS

Health Insurance 331D-G-0708

Reinstatement Application for NC

Health Insurance 819c-1004

Reinstatement Application for ND

Health Insurance 330D-G-0807

Reinstatement Application for NM

Health Insurance 672D-G-0609

Reinstatement Application for NV

Health Insurance 135D-G-0708

Reinstatement Application for OH

Health Insurance 137D-0108

Reinstatement Application for OK

Health Insurance 821C-G-0109

Reinstatement Application for PA - Association Group (FACT Fee)

Health Insurance 140D-0705

Reinstatement Application for PA - True Individual

Health Insurance 342D-G-0908

Reinstatement Application for SC - Association Group (FACT Fee)

Health Insurance 335D-G-0807

Reinstatement Application for SC - True Individual

Health Insurance 094D-G-0908

Reinstatement Application for TN

Health Insurance 262D-G-1008

Reinstatement Application for TX - Association Group (FACT Fee)

Health Insurance 092D-0205

Reinstatement Application for TX - True Individual

Health Insurance 474D-G-0908

Reinstatement Application for VA

Health Insurance 142D-G-0908

Reinstatement Application for WI

Health Insurance 493D-G-0708

Reinstatement Application for WV

IRS W-9 Form - Click this link to go to the IRS Web site to download the W-9 Request for Taxpayer Identification and Certification form.